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

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service January 12, 
2022. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
code 93976. 
 
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 76705 
is a column II code to column I code 39376. 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 76705 billed for date of service January 12, 
2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ED visit provided on August 31, 2021, 
and the ambulance transport provided on November 11, 2021. 
 
You asked the Plan to waive the copayment for the ED visit and ambulance transport. You say that are 
appealing the copayments applied. The Plan denied your request. The Plan says you have been charged the 
correct copayment amounts. 
 
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 each emergency care service and a $200 copayment for ambulance transport.  
 
 You have been asked to pay a total of $290, a $90 copayment for the ED visit provided on August 31, 2021, 
and $200 copayment for the ambulance transport provided on November 11, 2021. The ED visit falls within the 
Emergency care benefit category and the ambulance transport service falls with the Ambulance services 
benefit category. This means that you have been asked to pay the correct amount based on your contract with 
the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. 
Therefore, we decided that the Plan does not have to waive the copayment for the emergency department (ED) 
visit provided on August 31, 2021, and the ambulance transport provided on November 11, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for emergency room services provided on 
April 21, 2021. 
 
You asked the Plan to waive the copayment for emergency room services. You say that you have Medicare and 
it should be covered. You say that you have not seen your plan doctor even once. The Plan denied your request. 
The Plan says you have been charged the correct copayment 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 $90 
copayment for emergency services provided at an in-network emergency room.  
 
You have been asked to pay a $90 copayment for the emergency room services. The emergency room services 
fall within the Emergency Care 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 
emergency room services provided on April 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical (portable) ventilator (E0466). 
 
 
You asked the Plan to pre-approve the home mechanical (portable) ventilator (E0466). You say that you would 
like reconsideration because the device is to be used for the treatment of COPD and OSA. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in AVAPS mode with Auto-EPAP 
(AE) that could 
be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home mechanical (portable) 
ventilator (E0466). Our reviewer says that a home ventilator is not medically necessary. Our physician 
reviewer found you have a diagnosis of COPD, but there are no pulmonary function tests to confirm.  You are 
not on any long-acting controller medications, suggesting the COPD is not severe.  There is no documentation 
of chronic CO2 retention with an arterial blood gas while stable as an outpatient. You have has obstructive 
sleep apnea (OSA) but there is no documentation that it is being adequately treated. Medicare does not pay for 
a home ventilator when used as BiPAP. 
 
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 home mechanical (portable) ventilator (E0466) have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a home mechanical (portable) ventilator 
(E0466).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a mobile x-ray provided to the enrollee on September 22, 
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 this should have been billed with no modifier if billing for both components. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
It was not appropriate to bill the professional and technical component along with a modifier. 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 a mobile x-ray provided to the enrollee on September 22, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve admission to a SNF. You say that the requested admission to a SNF for 
rehab is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria 
for SNF admission. 
 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 admission to a SNF. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found based on the medical records 
provided there is no documentation that the enrollee requires skilled nursing services, i.e., the specialized skill, 
knowledge and judgment of a skilled professional nurse are not required to safely and effectively provide 
medically necessary and reasonable treatment. Records do not document the need for intravenous medications, 
new tube feeding, or ostomy care or daily complex wound care. Based on the medical records provided this 
enrollee does require skilled therapy services, i.e., the specialized skill, knowledge and judgment of a qualified 
therapist are required to safely and effectively provide medically necessary and reasonable treatment. Based on 
the medical records provided there is no documentation that daily skilled services are required. The enrollee is 
walking household distances with a front-wheeled walker with stand-by assistance and is stand-by assist for 
transfers. Provided records do not document a significant decline in the enrollees functional status to 
necessitate daily inpatient skilled therapy services. Based on the medical records provided there is no 
documentation that the enrollee requires the services on an inpatient basis, only in a skilled nursing facility 
setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of admission to a SNF have not been met. Therefore, we decided that the Plan 
does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466). 
 
 
You asked the Plan to pre-approve a home mechanical ventilator (E0466). You say that you would like 
reconsideration because the device is to be used for the treatment of COPD. 
 The Plan denied your request. The Plan says the request for a home mechanical ventilator set in iVAPS mode 
with Auto-EPAP (AE) that could 
be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home mechanical ventilator (E0466). Our reviewer says that a home ventilator is not medically necessary. Our physician reviewer found you have s 
COPD and congestive heart failure (CHF), and were recently hospitalized with exacerbation of both, and 
pneumonia.  Arterial Blood Gas (ABG) when acutely ill showed mild elevation of partial pressure of carbon 
dioxide.  There is no ABG as an outpatient when stable to confirm chronic CO2 retention.  BiPAP, with or 
without AVAPS, has not been tried at home. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home mechanical ventilator (E0466) have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a home mechanical ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing panel provided on September 8, 2021. 
 
You asked the Plan to pay for the genetic testing panel. You say that this is medically necessary testing. The 
Plan denied your request. The Plan says the documentation does not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple 
genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one 
panel code.  
 
We looked at the file and Medicare rules. This is an NGS test that was billed with multiple individual codes 
and not the single panel code as required. Based on this information, we decided that Medicare rules for 
coverage of the genetic testing panel have not been met. Therefore, we decided that the Plan does not have to 
pay for the genetic testing panel provided on September 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home mechanical (portable) ventilator (E0466). 
 
You asked the Plan to pre-approve a home mechanical (portable) ventilator. You say that you would like 
reconsideration because the deivce is to be used for the treatment of scoliosis with restriction. The Plan denied 
your request. The Plan says the request for a home mechanical ventilator set in TTV-VAPS mode with or 
without Auto-EPAP 
(AE) that could be delivered by BiPAP is not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a home mechanical (portable) 
ventilator. Our reviewer says that a home ventilator is not medically necessary. Our physician reviewer found 
this enrollee likely has restrictive lung disease as a consequence of severe scoliosis, with post-polio syndrome possibly contributing. This would be considered thoracic restrictive disease. However, there are no pulmonary 
function tests to confirm restriction and assess severity. There is no diagnosis of COPD. There is no 
documentation of chronic CO2 retention with an arterial blood gas (ABG) done while stable as an outpatient.  
If there is chronic CO2 retention, BiPAP during sleep is the appropriate treatment, and has not been tried as an 
outpatient.  Medicare does not pay for a home ventilator when used as BiPAP. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a home mechanical (portable) ventilator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a home mechanical (portable) ventilator (E0466).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the hereditary cardiovascular disease screening provided on 
September 9, 2021. 
 
You asked the Plan to pay for the hereditary cardiovascular disease screening. You say that this was medically 
necessary testing. The Plan denied your request. The Plan says this testing is considered to be a noncovered 
screening. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
 
We looked at the file and Medicare rules. The ordering provider is a pain management specialist. A pain 
management specialist does not treat cardiovascular conditions and would not use the results of this testing in 
the management of the enrollee's condition. Based on this information, we decided that Medicare rules for 
coverage of the hereditary cardiovascular disease screening have not been met. Therefore, we decided that the 
Plan does not have to pay for the hereditary cardiovascular disease screening provided on September 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia services provided to the enrollee on November 2, 
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 documentation does not include the sedation or anesthetic provided in the anesthesia record. 
 
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 01936 is "Anesthesia for percutaneous image guided 
procedures on the spine and spinal cord; therapeutic." 
 
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  Our reviewer found the 
records did not contain documentation to support the coding criteria for the code billed (CPT code 01936) on 
the date of service. Although the patient was documented as ASA 3, there was no medical necessity 
documented to require an anesthesia provider to be present for the enrollee's procedure. In addition, the 
enrollee did not have an IV inserted for the procedure in anticipation of administering any intra-procedural medications for sedation, patient anxiety, or pain control. The patient did not receive any medication for the 
procedure. It was not medically necessary or reasonable for this enrollee to have an anesthesia provider present 
for the procedure performed. 
 
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 anesthesia services provided to the enrollee on November 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Adjacent tissue transfer, or rearrangement (14301) 
provided on October 29, 2021. 
 
You asked the Plan to pay for code 14301. You say that the medical records support the billing of code 14301 
provided on October 29, 2021. The Plan denied your request. The Plan says the medical records do not support 
the billing of code 14301 provided on October 29, 2021. 
 
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 14301 is Adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm. 
 
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 code 14301. Our reviewer says that the medical records do 
not support the billing of code 14301 provided on October 29, 2021. Our reviewer found the enrollee had a melanoma on her right foot, measuring approximately 5 cm x 2.7 cm. The resected soft tissue specimen 
measured 6 cm x 5 cm. A clean wound bed was noted in preparation for graft application and wound VAC 
application. The documentation in the Full Operative Note does not support the billing of code 14301 
(Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm) provided on October 29, 
2021. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 14301 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Adjacent tissue transfer, or rearrangement (14301) provided on October 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOneCDx test provided to the enrollee on 
August 30, 2021.  
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the off-label use of molecularly targeted agents outside of clinical trials is not encouraged. 
 
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 pay for the testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the FoundationOneCDx test is a tissue-based genomic test for solid tumors like lung cancer, colorectal 
cancer, breast cancer, and prostate cancer. Molecular targeted agents outside of clinical trials has not been 
approved for treatment of the enrollee's condition. The review has determined that the enrollee did not meet the 
criteria for this testing. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the FoundationOneCDx test provided to the enrollee on August 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation trips. 
 
You asked the Plan to pre-approve additional routine transportation trips. You say that you require additional 
transportation trips. The Plan denied your request. The Plan says that you have exhausted this benefit. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of forty (40) trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided May 16, 2022 to 
May 17, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you were in a car accident that left you 
unconscious and you were transported to the hospital. You were unconscious during the time of arrival and it 
was not your choice to go to the hospital. The Plan denied your request. The Plan says the records do not 
support that the inpatient admission was not reasonable or medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer 
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the review indicates that the enrollee was admitted to the hospital on May 16, 2022 
after being in a car accident. He was found to have bruising from his seatbelt, and there was concern for a 
possible brain bleed of very small size. On further exam the findings on your imaging this decided to be 
insignificant, and he received no major treatment while in the hospital. The record sent by your provider 
indicates that you were safe for discharge home on May 17,2022. The review has determined that the did not 
record show that at the time of inpatient admission the admitting physician reasonably expected that the 
patient's necessary hospital care (including earlier ED and/or observation care) would 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 acute inpatient hospital care have not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided May 16, 2022 to May 17, 2022.