Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99214) provided on January 21, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the evaluation and management service. You say that the enrollee had moved. 
You also say that their Medicare plan, at the time, had not been changed to their new location yet. The Plan 
denied your request. The Plan says the enrollee's primary care physician did not refer them for the service. The 
Plan also says there is no medical necessity for an out-of-network provider.  
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the office visit (99214) provided on January 21, 2022, by an out-
of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional Modivcare mileage (A0170). 
 
You asked the Plan to pre-approve additional mileage. You say that the enrollee says it is difficult to drive far 
due to involuntary movements. The Plan denied your request. The Plan says the enrollee is requesting an 
additional 17 miles for a total of 92 miles. The enrollee's benefit only allows 75 miles. The enrollee has 
exceeded her benefit limit. 
 
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 up to 60 one-way trips and each one-way trip must not exceed 75 miles of driving 
distance.  We looked at your request, the records in the case file, and the rules. Specifically, trips over 75 miles are not 
covered. Based on this information, we decided that the Plans rules for coverage of routine transportation have 
not been met. Therefore, we decided that the Plan does not have to pre-approve additional Modivcare mileage 
(A0170).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the exchange nephrostomy catheter, percutaneous, including 
diagnostic nephrostogram and/or ureterogram when performed, imaging guidance and all associated 
radiological supervision and interpretation (50435) provided on February 17, 2021. 
 
You asked the Plan to pay for the physician service. You say that the service rendered was related to the 
enrollee's hospice election. The Plan denied your request. The Plan says [Enter plan denial rationale, e.g. 
"...rules for SNF care have not been metthe enrollees claim would be covered under Original Medicare as it is 
responsible for coverage of Part B benefits starting on the date of election until the last day of the month in 
which hospice is revoked. The Plan also says it is the providers responsibility to verify the enrollees coverage 
before rendering services and to know proper billing procedures for a Medicare Advantage member on hospice.  
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 exchange nephrostomy catheter, percutaneous, including 
diagnostic nephrostogram and/or ureterogram when performed, imaging guidance and all associated 
radiological supervision and interpretation (50435) provided on February 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an Intracept procedure. 
 
You asked the Plan to pre-approve an Intracept procedure. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
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 an Intracept procedure. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the intracept procedure is experimental. 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 an Intracept procedure have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an Intracept procedure.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ophthalmological services: medical examination and 
evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits, 
(92004) provided on June 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the vision care. You say that the providers rely on facility staff to verify 
eligibility and obtain authorization. The Plan denied your request. The Plan says prior authorization was not 
obtained before the service was rendered. The Plan also says that the service was not urgent or emergent. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care.  
The provider in this case is not a network provider with the Plan. The Plan did not pre-approve the item/service 
at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we 
decided that the Plan does not have to pay for the ophthalmological services: medical examination and 
evaluation with initiation of diagnostic and treatment program; comprehensive, new patient, 1 or more visits, 
(92004) provided on June 9, 2022, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit (99285) provided on March 
13, 2022. 
 
You asked the Plan to pay for procedure code 99285. You say that the medical records support the billing of 
code 99285. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99285. 
 
The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect 
the services provided.   
 
In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the 
evaluation and management of a patient which requires three components (taking into account the urgency of 
the clinical condition or the patient's mental status): 
 
1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity. 
 In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate 
significant threat to life or physiologic function.  
 
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 procedure code 99285 Our reviewer says 
that the medical records do not support the billing of code 99285. Our reviewer found the review indicates that 
the enrollee was with a history of coronary artery disease (CAD)- status post myocardial infarction (MI), 
Ventricular tachycardia (VT), and Gastroesophageal reflux disease (GERD) who presented to the emergency 
department (ED) on March 13, 2022, with chest pain and left arm numbness x 1 1/2 hours. In the ED she was 
chest pain free. Her vital signs were stable, physical exam and laboratory studies were normal. Her 
electrocardiogram (EKG) demonstrated normal sinus rhythm with non-specific ST-segment and T-wave (ST-T) 
changes. She was treated with aspirin and Nitroglycerin. Her condition stabilized and improved, and she was 
discharged home. The review has determined that the medical records did not support the billing of code 
99285. Specifically, the presenting problem(s) did not pose an immediate significant threat to life or 
physiologic function. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99285 have not been met. Therefore, we decided that the Plan 
does not have to pay for the emergency department visit (99285) provided on March 13, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service April 24, 
2022. 
 
You asked the Plan to pay for procedure code 70450. You say that the records should be reviewed to allow 
payment for this service. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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 procedure code 70450 billed for date of service April 24, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for tempus tumor origin testing (81479) billed for date of service 
November 29, 2021. 
 
You asked the Plan to pay for laboratory testing. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that the date of service for a 
clinical laboratory test or the technical component of a physician pathology service must be the date the 
specimen was collected. The specimen was collected on October 20, 2021, rather than the billed date of service 
of November 29, 2021. 
 
The Plan must follow Medicare rules. The rules say that generally, laboratory services should be reported with 
the date of specimen collection as the date of service; however, there are three exceptions to this rule. The rules 
also 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. Specifically, the Plan has not acknowledged nor addressed the exceptions to the 
applied rule. The specimen in this case was a live tumor sample tissue which was collected as part of a hospital 
procedure. It is very likely that an exception to the general rule has been met in this case, which would mean 
that the date of testing, November 29, 2021, would be the correct date to report. Therefore, we decided that the 
Plan has to pay for tempus tumor origin testing (81479) billed for date of service November 29, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an ultrasonic guidance for placement of radiation 
therapy fields (G6001x25). 
 
You asked the Plan to pre-approve an ultrasonic guidance for placement of radiation therapy fields. You say 
that ultrasonic guidance for placement of radiation field placement has been ordered by physician for 
evaluation of the ultrasound tumor depth/volume along with appropriate field placement, which will be 
ongoing through course of treatment, and is deemed medically necessary and appropriate ensuring efficacy of 
treatment. The Plan denied your request. The Plan says the requested service is not medically necessary for 
superficial radiation therapy. 
 
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 an ultrasonic guidance for placement of 
radiation therapy fields. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found usually IGRT is used when critical 
structures are abutting or in close proximity to the target that is being treated to high doses. This situation does 
not apply to this enrollee for which the target lesion can be seen on the skin to assist in daily set up. When 
treating skin cancers, there is generally not a need for IGRT unless deep structures are being treated. Certainly, 
using ultrasound on a daily basis is not unreasonable to offer but not necessary. Therefore, to bill for daily 
simple simulations and/or IGRT for a technology for which need has not been established by published data or 
supported by consensus guidelines (many of which recommend against treatment with these devices in general) 
is not necessary. The decision is unfavorable as billing for daily simulations (also requested in this case) or 
IGRT would not be furnished in accordance with accepted standards of medical practice. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an ultrasonic guidance for placement of radiation therapy fields have not been 
met. Therefore, we decided that the Plan does not have to pre-approve an ultrasonic guidance for placement of 
radiation therapy fields (G6001x25).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient office visit (99202) manual therapy techniques 
(97140) and infrared therapy (97026) provided May 17, 2022 to May 31, 2022. 
 
You asked the Plan to pay for the outpatient services. You say that you would like to make an appeal for the 
denial of payment for services for acupuncture which began May 17, 2022. The Plan denied your request. The 
Plan says these services are not covered under the Plan benefits. 
 The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 
sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the 
Plans rules apply in this case.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, the Plan allowed a one-time exception to allow 
payment for the acupuncture services only. The office visit, manual therapy techniques and infrared therapy are 
not covered under the Plan benefits. Therefore, we decided that the Plan does not have to pay for the outpatient 
office visit (99202) manual therapy techniques (97140) and infrared therapy (97026) provided May 17, 2022 to 
May 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 25, 2022, billed with 
codes 0031U, 0032U, 81225, 81227, 81230, 81231, 81291, and 81355. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
to treat the enrollee. The Plan denied your request. The Plan says NGS panel testing should be billed using one 
Current Procedural Terminology (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 
April 25, 2022, billed with codes 0031U, 0032U, 81225, 81227, 81230, 81231, 81291, and 81355.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an incisional biopsy of oral tissue for tooth #30 
(D7286). 
 
You asked the Plan to pre-approve an incisional biopsy of an oral tissue. You say that you have a growth in 
your mouth and your surgeon told you it was concerning, and you need to get a biopsy as soon as possible 
because the growth is getting bigger as the days go by. The Plan denied your request. The Plan says the 
requested service is not covered under your benefit plan. 
 
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. Therefore, we decided that the Plan does not have to pre-approve an 
incisional biopsy of oral tissue for tooth #30 (D7286).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve biological materials on tooth #16 (D4265). 
 
You asked the Plan to pre-approve biological materials. You say that you disagree with the denial of dental 
services. The Plan denied your request. The Plan says biological materials (D4265) are not covered by the 
enrollee's dental benefits. 
 
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. Therefore, we decided that the Plan does not have to pre-approve 
biological materials on tooth #16 (D4265).
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care associated with an elective surgery. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee is in pain and needs 
surgery. The Plan denied your request. The Plan says that an inpatient admission is not 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 supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that documentation is evident regarding a significant past and/or current medical history that 
would place this enrollee at increased risk for peri-surgical complications requiring an inpatient stay. This 
includes the chronic advanced kidney disease, the planned lengthy/invasive shoulder procedure with expected 
large quantity of 'fluid' exchanges', recumbent position, anesthesia effects with additional need for enforced 
neurovascular checks and extensive pain control. There is compelling rationale/circumstances noted to support 
the medical necessity of this request as an exception to guidelines. Therefore, the record shows that at the time 
of inpatient admission, the admitting physician would reasonably expect that the enrollees necessary hospital 
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 been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care associated with an elective surgery.  
 
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.