Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for occupational therapy services provided by an occupational 
therapy assistant on March 11, 2021. 
 
  You asked the Plan to pay for the occupational therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate if services are not available from preferred providers. You 
say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your 
request. The Plan says the records do not support the code billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of an occupational therapy assistant 
(OTA) shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, 
because they do not meet the qualifications of a therapist. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the occupational therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, OTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for occupational therapy 
services provided by an occupational therapy assistant on March 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (81121, 81120, 81201, 81210, 81270, 
81235, 81272, 81293, 81276, 81275, 81310, 81321, 81314, 81311, 81400, 81401, 81402, 81403) provided on 
January 20, 2021. 
 
You asked the Plan to pay for Guardant360 testing. You say that this is a covered service. The Plan denied your 
request. The Plan says this is not supported in the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. The rules also say that code 81479 is used to 
report Guardant360. You can find this rule in Local Coverage Article: Billing and Coding: Guardant360 
(A58192).  
We find that CPT codes 81121, 81120, 81201, 81210, 81270, 81235, 81272, 81293, 81276, 81275, 81310, 
81321, 81314, 81311, 81400, 81401, 81402, and 81403 are not supported in the medical record. Specifically, 
these codes were used to report Guardant360 testing, which should be billed with 81479. Based on this 
information, we decided that Medicare rules for coverage of Guardant360 testing have not been met. Therefore, 
we decided that the Plan does not have to pay for Guardant360 testing (81121, 81120, 81201, 81210, 81270, 
81235, 81272, 81293, 81276, 81275, 81310, 81321, 81314, 81311, 81400, 81401, 81402, 81403) provided on 
January 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound provided on July 7, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the ultrasound. You say that the enrollee was referred by their primary care 
physician to receive this service. The Plan denied your request. The Plan says authorization was not obtained 
before the services were rendered to the enrollee. The Plan also says that the referring provider is not a 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 referring provider is not a network 
provider with the Plan either. 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 ultrasound provided on July 7, 2021, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the unlisted special service, procedure or report (99199) 
provided on May 28, 2021. 
 
You asked the Plan to pay for the unlisted special service. You say that this claim should be reprocessed based 
on the medical documentation. The Plan denied your request. The Plan says this claim is missing required 
information. 
 
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 99199 is unlisted special service, procedure or report. 
 
We find that CPT code 99199 is not supported in the medical record. Specifically, the medical documentation 
provided does not include a narrative report that adequately describes the services coded as an unlisted special service, procedure or report. Based on this information, we decided that Medicare rules for coverage of the 
unlisted special service have not been met. Therefore, we decided that the Plan does not have to pay for the 
unlisted special service, procedure or report (99199) provided on May 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the catheters, guide wires, fixed 
introducer, and vascular closure device supplies, the computed tomography (CT) scan of the heart, the 
electrophysiology studies, the doppler echocardiography, the transesophageal echocardiography, the 
transthoracic echocardiography, and the injected drugs you received on April 13, 2021. 
 
You asked the Plan to reduce the cost sharing for the medical supplies, the CT scan, the electrophysiology 
studies, the echocardiography tests, and the injected drugs. You say that all of these items should be covered 
under a single $300 copayment. The Plan denied your request. The Plan says you were charged these cost 
sharing amounts 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 diagnostic tests, surgical supplies, and Medicare Part B drugs, and a $175 copayment for 
advanced imaging services.  
 
You have been asked to pay 20% coinsurance for the medical supplies, the electrophysiology studies, the 
echocardiography tests, and the injected drugs. You have also been asked to pay a $175 copayment for the CT 
scan.  The electrophysiology studies and the echocardiography tests fall within the diagnostic tests benefit 
category. The catheters, guide wires, fixed introducer, and vascular closure device supplies all fall within the 
surgical supplies benefit category.  The CT scan is considered an advanced imaging service, and the injectable 
drugs you received are considered Medicare Part B drugs.   
 
Your Evidence of Coverage says that when you have outpatient surgery, certain items have separate cost 
sharing.  Separate cost sharing can apply to diagnostic tests, supplies, and Medicare Part B drugs.  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 reduce the cost sharing for the catheters, guide wires, fixed introducer, and vascular closure 
device supplies, the computed tomography (CT) scan of the heart, the electrophysiology studies, the doppler 
echocardiography, the transesophageal echocardiography, the transthoracic echocardiography, and the injected 
drugs you received on April 13, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan 
denied your request. The Plan says the denial of authorization for SNF care is correct. 
 
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 care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not have daily skilled 
nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. The 
enrollee does not have daily skilled therapy needs that require the specialized skill, knowledge, and judgment 
of a skilled professional therapist. The enrollee does not require daily skilled nursing and/or skilled therapy on 
an inpatient basis in a skilled nursing facility (SNF) 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the electric stimulation therapy provided on September 22, 
2020. 
 
You asked the Plan to pay for the electric stimulation therapy. The Plan denied your request. The Plan says the 
billed code is not valid for Medicare purposes. 
 
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 97014 is application of a modality to 1 or more areas; 
electrical stimulation (unattended). 
 
 
  We find that CPT code 97014 is not supported in the medical record. Specifically, per the Physician Fee 
Schedule, CPT code 97014 has a status indicator of I. This means that CPT code 97014 is not valid for 
Medicare billing purposes. Based on this information, we decided that Medicare rules for coverage of the 
electric stimulation therapy have not been met. Therefore, we decided that the Plan does not have to pay for the 
electric stimulation therapy provided on September 22, 2020.
Appeal type: Transportation
Decision: Unfavorable

 We decided the Plan does not have to waive the $150 copayment for ambulance transport provided on April 15, 
2021. 
 
You asked the Plan to waive this copayment. You say that went to a radiology provider who you believe 
caused damage your kidney. You stated you were rushed to the emergency room and they saved your life. You 
stated it was not your fault you needed this transport and should not have to pay for it. The Plan denied your 
request. The Plan says this copayment is a contractual obligation based on the service provided. 
 
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 $150 for 
ambulance transport. The Plan has paid their portion of the cost of this service. 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 $150 
copayment for ambulance transport provided on April 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the critical care services coded as 99291 provided on March 
25, 2021. 
 
You asked the Plan to pay for the critical care services. You say that you would like this claim reprocessed 
based on medical documentation. The Plan denied your request. The Plan says the documentation submitted 
does not support the services as 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 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
We find that CPT code 99291 is not supported in the medical record. Specifically, the medical records 
submitted for this appeal only document that 15 minutes of critical care services were performed. Based on this 
information, we decided that Medicare rules for coverage of the critical care services have not been met. 
Therefore, we decided that the Plan does not have to pay for the critical care services coded as 99291 provided 
on March 25, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the bone replacement graft (D7953) provided on September 
1, 2021. 
 
You asked the Plan to pay for the bone replacement graft (D7953). You say that you had a bacterial infection 
under the gum which caused having to get the bone graft. You say that it was medically necessary to build up 
the area and be able to chew correctly. The Plan denied your request. The Plan says the bone replacement graft 
is not a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan?s 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 pay for the bone 
replacement graft (D7953) provided on September 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug administered through a metered dose inhaler 
provided during an outpatient hospital stay from February 2, 2021, to February 3, 2021 billed with code J3535. 
 
You asked the Plan to pay for the drug administered through a metered dose inhaler. You say that this has been 
incorrectly denied and an additional $84.65 is due from the Plan. The Plan denied your request. The Plan says 
this was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The rules also say that providers must code services correctly. 
 
In this case, code J3535 has a status indicator of E1 in the Outpatient Prospective Payment System (OOPS), 
which makes payment for outpatient hospital services. This indicator means that it is not paid by Medicare 
when submitted on outpatient claims. This code represents a drug which enrollees would usually self-
administer. This means that it is not covered by Medicare Part B. Therefore, we decided that the Plan does not 
have to pay for the drug administered through a metered dose inhaler provided during an outpatient hospital 
stay from February 2, 2021, to February 3, 2021 billed with code J3535.  
 
Benefits for the drug administered through a metered dose inhaler 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: Imaging
Decision: Unfavorable

 
We decided the Plan does not have to pre-approve computed tomography (CT) scan of the thoracic spine.  
 
You asked the Plan to pre-approve computed tomography (CT) scan. You say that this imaging is medically 
necessary. The Plan denied your request. The Plan says Medicare coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 computed 
tomography (CT) scan. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer 
found the enrollee has worsening neck pain with radiation to bilateral shoulders/arms and numbness/tingling to 
arms/hands. Physical exam showed kyphosis of neck, motor function rated 4 out of 5 in upper extremities with 
sensation grossly intact. The x-ray showed worsening kyphosis of cervical spine and fusion C2-3 through C6 
unchanged compared to 2020. A thoracic spine CT was requested. Neck injections were considered. The 
enrollee was not offered surgical options for improving neck pain and injections were considered but not 
planned. Repeat imaging would be best done when surgery is more seriously considered and other more 
conservative treatments have been exhausted. Medicare criteria for this imaging are not met. We looked at this 
physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of computed tomography (CT) scan have not been met. Therefore, we decided that the Plan does not 
have to pre-approve computed tomography (CT) scan of the thoracic spine for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets the criteria for an IRF stay. You 
say that a lower level of care cannot provide the total interdisciplinary team approach that is needed. The Plan 
denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says 
that the enrollee could receive the care needed in another setting. 
 
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 the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for pneumonia, urinary tract infection, and sepsis. The enrollee's medical problems are stable. 
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple 
therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the documentation does support a need for physical and/or occupational therapy, there is no 
documented need for a intensive, multi-disciplinary rehabilitation program. There is not a reasonable 
expectation that the enrollee will be able to fully participate in and benefit from the intensive rehabilitation 
therapy program provided in an IRF. 
 
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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the lumbar 
spine (72148). 
 
You asked the Plan to pre-approve the MRI of the lumbar spine. You say that this imaging service is medically 
necessary. The Plan denied your request. The Plan says the criteria for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are 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 MRI of the lumbar spine. Our 
reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer 
found that the patient is an 83-year-old male who reported poor balance, lightheadedness, and unsteadiness. He 
denied any sudden weakness. He has not tried physical therapy (PT) for the gait and balance before. Physical 
examination revealed normal strength and sensation in the lower extremities. He had slight ataxic gait. PT was 
prescribed and lumbar MRI was requested. Although including neuropathy in the differential is reasonable, 
there was no clear exam findings or history to suggest a red flag diagnosis to justify MRI prior to a trial of PT 
which was also ordered and should be completed with follow-up before considering any other testing. 
Therefore, this request for MRI will be considered not medically necessary at this time.  
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physician services billed to the enrollee from August 1, 
2020, to August 10, 2020. 
 
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your 
request. The Plan says Medicare billing criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 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 
these services. Our reviewer says that Medicare billing criteria are not met. Our reviewer found Clinical 
documentation does not support speech language pathology comorbidity coded for active diagnosis of 
Cerebrovascular Accident (CVA), Transient Ischemic Attack (TIA), or Stroke and that mechanically altered 
diet was provided. Medicare billing criteria are not met.  
 We looked at this coder'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 pay for physician services billed to the enrollee from August 1, 2020, to August 10, 2020.