Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pay for the durable medical equipment (E0627, E0260, E0265) and does not 
have to pay for the sales tax (S9999) provided from August 6, 2021, to August 23, 2021. 
 
You asked the Plan to pay for the durable medical equipment (E0627, E0260, E0265). You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the 
provider is not enrolled in the Medicare program. 
 
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 has not provided sufficient evidence to show that the provider is not 
enrolled in the Medicare program. As this is the Plan's only denial rationale, we find that the Plan has not 
proven their case to deny payment for these items.  
 
The rules also say contractors do not make any additional payment for sales taxes. We looked at the file and 
Medicare rules. Medicare does not make separate payment for sales tax. 
 
Therefore, we decided that the Plan has to pay for the durable medical equipment (E0627, E0260, E0265) and 
does not have to pay for the sales tax (S9999) provided from August 6, 2021, to August 23, 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 waive the cost-sharing for Hyaluronic Acid Injection on February 
17, 2022. 
 
You asked the Plan to waive the cost-sharing for injection. You say that you want the plan to advise you on 
what your share of the cost is for these services. The Plan denied your request. The Plan says the cost-sharing 
you are being charged is correct. 
 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 $10 
copayment for services obtained from a specialist or under certain circumstances, treatment by a nurse 
practitioner or physicians assistant or other non-physician health care professionals in a specialists office (as 
permitted under Medicare rules). Covered services include: Consultation, diagnosis, and treatment by a 
specialist. The provider billed in the amount of $1,680 and the Plan allowed $539.52. The Plan paid $345.70. 
This results in the remaining deductible amount of $193.82. The provider also billed in the amount of $350 and 
the Plan allowed $67.92. The Plan paid $57.92 which result in a $10 copayment. Therefore, the $193.82 + $10 
copayment results in the total cost-sharing amount of $203.82.   
 
You have been asked to pay a $10 copayment and a $193.82 deductible for injection. Injection falls within the 
Physician/Practitioner Services, Including Doctors Office Visits 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 cost-sharing for Hyaluronic Acid Injection on February 17, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, first hour (99291) provided on September 23, 
2021. 
 
You asked the Plan to pay for critical care. You say that this service was billed appropriately. The Plan denied 
your request. The Plan says this service was billed for two units on the date in question, but Medicare 
regulations only allow one unit of this service per day. There is another procedure code which is used to report 
additional minutes of critical care. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  In this case, the MUE for CPT code 99291 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Please note that there is another procedure code which is used to report additional 
minutes of critical care. Based on this information, we decided that Medicare rules for coverage of critical care 
have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) 
provided on September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 12, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services are 
experimental. 
 
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 
genomic sequencing procedure, molecular multianalyte assay, ultianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis CPT code.  
 
We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple 
codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. 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 genetic testing provided on November 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a backup battery. 
 
You asked the Plan to pre-approve a backup battery. You say that you would like the Plan to reconsider their 
denial. The Plan denied your request. The Plan says a backup battery is not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve a backup battery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for adjacent tissue transfer or rearrangement (14301, 14302) and 
surgical preparation of recipient site (15004) provided on November 17, 2021. 
 
You asked the Plan to pay for adjacent tissue transfer or rearrangement and surgical preparation of recipient 
site. You say that you have provided medical records to support the services at issue. The Plan denied your 
request. The Plan says the available medical 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 14301 is Adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm; of code 14302 is Adjacent tissue transfer or rearrangement, any area; 
each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure); and of 
code 15004 is Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or 
scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, 
neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children. 
 
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 adjacent tissue transfer or rearrangement and surgical 
preparation of recipient site. Our reviewer says that the services at issue do not meet criteria for payment. Our 
reviewer found that the operative report does not describe adjacent tissue transfer and therefore codes 14301 
and 14302 cannot be verified as performed. The operative report describes debridement of nonviable 
tissue. Surgical preparation codes would not be reported for removal of nonviable tissue or debris of chronic 
wound. Therefore, CPT code 15004 cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of adjacent tissue transfer or rearrangement and surgical preparation of recipient 
site have not been met. Therefore, we decided that the Plan does not have to pay for adjacent tissue transfer or 
rearrangement (14301, 14302) and surgical preparation of recipient site (15004) provided on November 17, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder Detect (0012M) provided December 6, 2021. 
 
You asked the Plan to pay for CxBladder Detect. You say that you believe the evidence supporting the use of 
CxBladder a medically necessary diagnostic service is well established and affirmed by Medicare. The Plan 
denied your request. The Plan says CxBladder Detect is not an approved test with Palmetto GBA and has not 
been evaluated by the MoIDx programs technical assessment process. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. CxBladder Detect has not been evaluated for Medicare coverage by 
the MoIDx program administered by Palmetto GBA. Only CxBladder Monitor has been evaluated and it is 
noncovered. Based on this information, we decided that Medicare rules for coverage of CxBladder Detect have 
not been met. Therefore, we decided that the Plan does not have to pay for CxBladder Detect (0012M) 
provided December 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for laryngoscopy provided on March 2, 2022. 
 
You asked the Plan to waive the copayment for laryngoscopy. You say that this was performed in an 
observation room, so the charges are incorrect. The Plan denied your request. The Plan says the copayment 
applied is correct. 
 
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 $275 
copayment for each Medicare-covered outpatient hospital facility visit.  
 
You have been asked to pay $163.03 which is less than the standard $275 copayment for laryngoscopy. The 
laryngoscopy falls within the Outpatient Surgery, Including Services Provided at Hospital Outpatient Facilities 
and Ambulatory Surgical Centers 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 
laryngoscopy provided on March 2, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for acupuncture provided on  December 27, 2021, and January 
27, 2022. 
 
You asked the Plan to pay for acupuncture. You say that you enclosed a letter from your primary care 
physician stating that your lower back pain is indeed a reoccurring problem. The Plan denied your request. The 
Plan says evidence of the problem lasting 12 weeks or longer was not presented. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of acupuncture provided on December 
27, 2021, and January 27, 2022, have been met. Specifically, no medical records were provided to support that 
you had chronic lower back pain that  lasted 12 weeks or more. Therefore, we decided that the Plan does not 
have to pay for acupuncture provided on  December 27, 2021, and January 27, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the member has no skilled therapy or skilled nursing service needs. 
 
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 SNF services. Our reviewer says that 
SNF services are not medically reasonable and necessary. The enrollee does not have documented skilled 
nursing needs. The enrollee currently does not appear to be on IV antibiotics. The enrollees wound care needs 
are not known. The enrollee does not have documented skilled therapy needs. The enrollee is non-ambulatory 
at baseline. The enrollee does not appear to be willing/able to participate in daily skilled therapy. Daily skilled 
services are not shown to be required to establish a maintenance program or to prevent deterioration of the 
enrollees condition. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria 
for SNF services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electronic analysis services (95984-59) provided on 
November 18, 2021. 
 You asked the Plan to pay for the electronic analysis services. You say that you would like this claim 
reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation does 
not support separate payment for CPT 95984-59. 
 
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 95984 is a column II code to column I code 61885; however, 95984 
was billed with a modifier.  
 
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 electronic analysis services. Our reviewer says that the 
documentation does not support separate payment for CPT 95984. Our reviewer found that the procedure 
report describes replacement of subclavicular internal pulse generator, and programing of device performed 
during the same session. In this case, electronic analysis would be included with the pulse generator 
replacement and would not be eligible for separate payment. Of note, procedure report does not include 
documentation of time to support additional time as also required by billing regulations. 
 
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 electronic analysis services have not been met. Therefore, we decided that 
the Plan does not have to pay for the electronic analysis services (95984-59) provided on November 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acupuncture treatment (97810, 97811) provided on 
December 11, 2020 and April 29, 2021. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the acupuncture services provided are not 
payable as they do not meet Medicare criteria for coverage. 
 
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.  
 
 We looked at the case file and Medicare rules. Based on this information, we decided that the rules for 
coverage of the acupuncture services provided have not been met. Specifically, the services in this case were 
provided by an acupuncturist who was not supervised by a physician, physician assistant, or nurse 
practitioner/clinical nurse specialist. Therefore, we decided that the Plan does not have to pay for the 
acupuncture treatment (97810, 97811) provided on December 11, 2020 and April 29, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve five (5) fractions (treatment sessions) of tomotherapy IGRT (CPT 
code(s): 77385, 77387, G6002, and G6015). 
 
You asked the Plan to pre-approve the services. You say that you would like this enrollee to have IGRT/IMRT 
as it is a safer treatment. The Plan denied your request. The Plan says that there is no current research showing 
that the enrollee's type of cancer responds better to the requested type of treatment than the type of treatment 
the Plan can approve. 
 
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 the services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the items/services at issue in this case are medically reasonable and necessary. National 
Comprehensive Cancer Network (NCCN) Guidelines Version 4.2022, Invasive Breast Cancer, states that 
improved homogeneity of the target dose and sparing of normal tissues can be accomplished using 
compensators including intensity-modulated radiation therapy (IMRT). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pre-
approve five (5) fractions (treatment sessions) of tomotherapy IGRT (CPT code(s): 77385, 77387, G6002, and 
G6015).  
 
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: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 11043 billed for date of service September 
17, 2021. 
 
You asked the Plan to pay for procedure code 11043. You say that modifier 58 was reported to indicate the 
services were performed by the same physician during the post- operative period. You say that CPT code 
11043 should be considered for separate reimbursement. The Plan denied your request. The Plan says payment 
for code 11043 is bundled into payment for code 12005.  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 11043 
is a column II code to column I code 12005. 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 11043 billed for date of service September 17, 
2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve facial feminization surgery including rhinoplasty 
(30420), genioplasty (21122), adjacent tissue transfer (15774) and fat grafting to the face (15773). 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that there is no clinical documentation for evidence of an abnormal 
structure caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional 
defects, or disease. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The record indicates 
that you have gender dysphoria. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. Our physician reviewer found that your 
condition does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve facial feminization surgery including rhinoplasty (30420), genioplasty (21122), adjacent 
tissue transfer (15774) and fat grafting to the face (15773).