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

 
We decided that the Plan does not have to pay for the pulmonary risk factor screening panel provided on July 
28, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the testing is 
not a covered benefit. 
 
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 records do not show that the pulmonary panel, billed with codes 81407, 81302, 81345, and 81330, was 
ordered for a specific medical problem. The test at issue in this appeal was requested solely for screening 
purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does 
not have to pay for the pulmonary risk factor screening panel provided on July 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99152 provided on August 10, 2022. 
 
You asked the Plan to pay for procedure code 99152. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the billing of code 
99152. 
 
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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not 
contain evidence that moderate sedation was performed with the presence of an independent trained observer. 
Based on this information, we decided that Medicare rules for coverage of procedure code 99152 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 99152 provided on August 
10, 2022.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the genetic testing provided to the enrollee on January 12, 2022.
You asked the Plan to pay for the genetic testing. You say that these services were ordered by the enrollee's
physician. The Plan denied your request. The Plan says the claim for this molecular pathology testing did not
include the required unique identifier.
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue,
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the
coverage status is listed in the DEXTM Diagnostics Exchange.
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier
was reported. 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 the genetic testing provided to
the enrollee on January 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the
enrollee.
You asked the Plan to pre-approve a group 3 power wheelchair and accessories. You say that the requested
group 3 power wheelchair is an upgrade to the current group 2 power wheelchair based on medical necessity.
The Plan denied your request. The Plan says that the that enrollee does not meet criteria as the enrollee has a
group 2 power wheelchair that meets their needs.
Our Medical director looked at the case file and the reopen request. At issues is coverage for a group 3 power
wheelchair and accessories. Our Medical Director states that the documentation does not sufficiently support
that the coverage criteria for the requested group 3 PWC and accessories were met in this case. The medical
records by the enrollee's physician do not support the medical necessity of the requested items. Therefore, we
decided that the Plan does not have to pre-approve a group 3 power wheelchair and accessories for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for Infusions provided on August 01, 2022. 
 
You asked the Plan to waive the coinsurance for Infusions. You say that you are disputing the share cost. 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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for Infusions. This item/service falls within the Medicare Part B 
prescription drugs 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 coinsurance for Infusions provided 
on August 01, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve vascular services, including angioplasty, arthretctomy, 
and/or stents. 
 You asked the Plan to pre-approve the requested services. You say that the enrollee complains of claudication 
of the lower extremities. The Plan denied your request. The Plan says the enrollee does not show any 
significant symptoms. 
 
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 requested services. Our physician 
reviewer found that the enrollee has claudication with 75 percent stenosis of the external iliac and superficial 
femoral arteries on the left. The record indicates that the enrollee has an ankle brachial index of 0.76 on the left.  
The record does not indicate the presence of lifestyle limiting claudication. The record does not indicate critical 
limb ischemia, a hemodynamically significant obstructive lesion, or the failure of a conservative exercise 
program. The record provided does not indicate that the enrollee has hemodynamically significant stenosis. 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. Therefore, the requested service is 
not recommended. 
 
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 vascular services, including angioplasty, arthretctomy, and/or stents.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve wound care services to be provided by an out-of-network provider. 
 
You asked the Plan to pre-approve the requested services. You say that you have gone to this provider for the 
last five years. The Plan denied your request. The Plan says that the service requested is available in-network. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that you receive your care from a provider who is eligible to provide services under Original 
Medicare.  
 
We looked at the file and Medicare rules. The requested provider is not a network provider with the Plan. 
However, you have out-of-network benefits through the point-of-service benefit. If you use an out-of-network 
provider, your share of the costs for your covered services may be higher. Based on this information, we 
decided that Medicare rules for coverage of the requested services have been met. Therefore, we decided that 
the Plan has to pre-approve wound care services to be provided by an out-of-network provider.  
 
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: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for surgical shoulder arthroscopy (procedure code 29823) provided to the 
enrollee on July 20, 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 that the records do not support the services 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. In this case, the CPT Code Manual definition of 
code 29823 is "Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, 
humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps 
anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, 
subacromial bursa, foreign body[ies])." 
 
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 supported by the medical records. Our reviewer found that the enrollee was being treated for 
bursitis of the right shoulder. She underwent an arthroscopic subscapularis repair, biceps tenodesis, rotator cuff 
repair suture bridge technique, extensive debridement, subacromial, lysis of adhesions, and synovectomy on 
7/21/21. Procedure details cite the rotator interval was debrided down to the base of the coracoid with the RF 
device. Extensive debridement was done of the glenohumeral joint with a shaver. Adhesions were encountered 
and a lateral portal was established. Lysis of adhesions was performed to the anterior, posterior, and lateral 
gutters with a shaver to debride the synovium. Anterolateral acromion was debrided with RF device and then a 
5.5mm bur was used to smooth the acromion. Therefore, the records do support that CPT 29823: arthroscopy, 
shoulder, surgical, debridement, extensive 3 or more discrete structures (e.g., humeral bone, humeral articular 
cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular 
capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]) 
was rendered in this case. 
 
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 been met. Therefore, we decided that the Plan has to pay for 
surgical shoulder arthroscopy (procedure code 29823) provided to the enrollee on July 20, 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six home health occupational therapy visits. 
 
You asked the Plan to pre-approve the home health occupational therapy visits. You say that you were told by 
both providers the home health services were approved. The Plan denied your request. The Plan says the 
services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or therapy.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the home health occupational therapy 
visits. Our reviewer says that the services are not medically reasonable and necessary. Our physician reviewer 
found the enrollee does not have documented skilled nursing needs. As such, the home health skilled services 
are not medically necessary or reasonable. 
 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 health occupational therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve six home health occupational therapy visits.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network emergency room (ER) visit 
provided on October 07, 2022, to October 10, 2022. 
 
You asked the Plan to waive the copayment for an in-network emergency room (ER) visit. You say that you 
would like this waived as you were admitted to the hospital. 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 $90 
copayment for emergency care. 
 
You have been asked to pay a $90 copayment for an in-network emergency room (ER) visit. This item/service 
falls 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 
an in-network emergency room (ER) visit provided on October 07, 2022, to October 10, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee meets the requirements for 
an LTACH admission, and you are requesting reconsideration based on the records submitted. The Plan denied 
your request. The Plan says the enrollee does not meet all the requirements for an LTACH admission. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services available at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to the LTACH is not medically necessary as it 
would not be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for code J3490 billed for date of service August 31, 2022. 
 
You asked the Plan to pay for code J3490. The Plan denied your request. The Plan says that payment is 
included in the payment for another service. 
 
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 argues that payment for code J3490 is included in the payment for 
another service provided on the same date. However, the Plan has not provided documentation showing that 
payment for code J3490 was included in another service billed. An NCCI edit does not exist between code 
J3490 and the other billed codes. Without supporting documentation, the plan's denial cannot be substantiated. 
Therefore, we decided that the Plan has to pay for code J3490 billed for date of service August 31, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Multaq. 
 
You asked the Plan to pre-approve Multaq. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug is not a covered 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 Multaq.  
 
Benefits for Multaq 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve i-Factor allograft for spine surgery. 
 
You asked the Plan to pre-approve allograft. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the effectiveness of this compared to other materials cannot be determined. 
 
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 allograft. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found i-Factor allograft is experimental in spine surgery, more research is needed to show safety and 
efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of allograft have not been met. Therefore, we decided that the Plan does not have 
to pre-approve i-Factor allograft for spine surgery.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says records show there is no need for the requested IRF 
services. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require, or to be able to tolerate, fifteen hours per week of 
rehabilitative services and regular physician evaluation. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (36415, 84443, 83036, 82607) provided on 
January 15, 2021. 
 
You asked the Plan to pay for the lab services. You say that it was not the provider's fault that the claims were 
not filed timely. The Plan denied your request. The Plan says the corrected claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the lab services was not filed until August 23, 2022. This means that more 
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that 
the Plan does not have to pay for the lab services (36415, 84443, 83036, 82607) provided on January 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you would like reconsideration based on 
the medical records submitted. The Plan denied your request. The Plan says the requested LTACH services are 
not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care services that can safely be provided at the current facility until more 
appropriate for a lower level of care. The enrollee does not require services at the LTACH that are not already 
available and covered at the current facility. Transfer to the LTACH is not medically necessary as it would not 
be clinically advantageous. Completion of treatment at the current facility is recommended. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.