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

 
We decided that the Plan does not have to pay for procedure codes 31629, 31625, 31623 and 99152 billed for 
date of service, February 28, 2022. 
 
You asked the Plan to pay for codes 31629, 31625, 31623 and 99152. You say that these services were reported 
correctly and are supported in the medical record. The Plan denied your request. The Plan says these services 
are not supported 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 31629 is bronchoscopy, rigid or flexible, including 
fluoroscopic guidance, when performed; with transbronchial needle aspiration biopsy(s), trachea, main stem 
and/or lobar bronchus was performed. The CPT Code Manual definition of code 31625 is bronchoscopy, rigid 
or flexible, including fluoroscopy guidance, when performed, with bronchial alveolar lavage. The manual 
definition of 31623 is bronchoscopy, rigid or flexible, including fluoroscopy guidance, when performed; with 
brushing or protected brushings, and the 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 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 codes 31629, 31625, 31623 and 99152. Our reviewer says 
that the documentation provided does not support the billing of these services. Our reviewer found that the 
procedure report provided does not include documentation of a bronchoscopy with needle aspiration biopsy, a 
bronchial alveolar lavage or brushings or protected brushings. These procedures cannot be verified. Although 
the procedure report does document moderate sedation, the procedure report does not include documentation of 
the presence of an independent trained observer to assist in the monitoring of the enrollees level of 
consciousness and physiological status. Therefore, code 99152 also 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 codes 31629, 31625, 31623 and 99152 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 31629, 31625, 31623 and 99152 billed for date 
of service, February 28, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on November 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that this should be paid for. The Plan denied your 
request. The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for lab services provided on November 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cytopathology (88112) provided December 5, 2019. 
 
You asked the Plan to pay for the cytopathology. You say that the enrollee was not in a covered skilled nursing 
facility stay on this date of service. The Plan denied your request. The Plan says this claim should not be 
separately reimbursed as they are covered under the Skilled Nursing Facility inpatient stay. 
 
The Plan must follow Medicare rules. Medicare rules say that services paid under Part A cannot be billed 
separately. 
 
We looked at the file and Medicare rules. The Plan provided documentation showing that the enrollee was in a 
covered skilled nursing facility stay on the date of service at issue. Based on this information, we decided that Medicare rules for coverage of the cytopathology have not been met. Therefore, we decided that the Plan does 
not have to pay for the cytopathology (88112) provided December 5, 2019.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the enrollee has low back pain. The 
Food and Drug Administration (FDA) has not stated that the requested drug is indicated for the enrollee's 
condition. The Medicare-approved drug compendia do not contain a supportive citation for the use of the 
requested drug in the enrollee's clinical situation.   Botox is not reasonable or medically necessary. 
 
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 Botox.  
 
Local Coverage Determination (LCD) L33274 referenced by the Plan is not valid for the state of West Virginia 
and was not used in the MAXIMUS determination.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the MRI of the breast on March 16, 2021. 
 
You asked the Plan to waive the copayment for the MRI of the breast. You say that you are on a fixed income 
and are not able to pay this. The Plan denied your request. The Plan says the cost share has been applied 
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 $60 for 
an MRI.  
 
 
 
 
 
 
 You have been asked to pay $60 for an MRI of the breast. An MRI of the breast falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. This means that you have been asked 
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation 
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive 
the copayment for the (MRI) of the breast on March 16, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 14, 2022, to 
March 18, 2022. 
 You asked the Plan to pay for the services provided. You say that the correct bill type 323 was used. The Plan 
denied your request. The Plan says the claim was billed with an incorrect type of bill. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. We find that the claim was not billed with a valid type of bill code suitable 
for payment. Based on this information, we decided that Medicare rules for coverage of the services provided 
have not been met. Therefore, we decided that the Plan does not have to pay for the home health services 
provided from March 14, 2022, to March 18, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services (procedure code 76937) provided to the 
enrollee on January 30, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this is an add-on code without a billed appropriate primary procedure code. 
 
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 75937 
is an add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for ultrasound services (procedure code 76937) provided to the enrollee on January 30, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76775 billed for date of service April 12, 
2022. 
 
You asked the Plan to pay for procedure code 76775. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 76775 is bundled into payment for code 76770. 
 
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 76775 
is a column II code to column I code 76770. 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 76775 billed for date of service April 12, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services (procedure code 76937) provided to the 
enrollee on January 25, 2022. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the Type II add-on code 76937 was not billed with an appropriate primary 
procedure code. 
 
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 76937 is an 
add-on code and has not been billed with an appropriate primary procedure code. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for ultrasound services (procedure code 76937) provided to the enrollee on January 25, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the artificial iris insertion (CPT code(s): C1839 and 
0616T) 
 
You asked the Plan to pre-approve the artificial iris insertion. You say that this procedure is to improve vision, 
eyesight, continuous irritation and discomfort. The Plan denied your request. The Plan says there is not enough 
evidence that this type of eye surgery is safe or effective; therefore, it not considered standard of care. 
 
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 artificial iris insertion. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the documentation in the case file is insufficient to support that an artificial iris is 
medically reasonable and necessary for you in this case. The clinical benefit of the procedure is not clearly 
supported in the medical literature 
 
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 artificial iris insertion have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the artificial iris insertion (CPT code(s): C1839 and 0616T)
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the parenteral nutrition (CPT code(s): B4185 and 
B4189). 
 
You asked the Plan to pre-approve the parenteral nutrition. You say that the nutrition therapy given through the 
enrollee's vein during dialysis would help them with their nutritional needs. The Plan denied your request. The 
Plan says the enrollee does not have a permanent problem with their digestive tract that keeps the enrollee from 
absorbing the food they eat. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the parenteral nutrition have not been met. There is no report the 
enrollee's stomach and intestine do not work properly. The appeal information includes a statement from the 
enrollee's doctor that states, they are able to take food and fluid by mouth. The enrollee does not have a 
condition that keeps nutrients from being absorbed. Therefore, we decided that the Plan does not have to pre-
approve the parenteral nutrition (CPT code(s): B4185 and B4189).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the radiology services provided on December 26, 2021. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are not 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that carriers may not pay for the TC of radiology 
services furnished to Skilled Nursing Facility (SNF) inpatients during a Part A covered stay.  
 
We looked at the file and Medicare rules. The radiology services in this case are not separately payable, as 
payment is included in the SNF PPS payment. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the 
radiology services provided on December 26, 2021.
Appeal type: Drugs
Decision: Favorable

 
We decided that the Plan has to pre-approve Procrit. 
 
You asked the Plan to pre-approve these services. You say that the services are not medically necessary. The 
Plan denied your request. The Plan says that the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that Procrit is covered when specific criteria are met. 
 
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 services are medically necessary. Our physician reviewer found the enrollee has anemia in the setting of 
receiving ongoing myelosuppressive chemotherapy for breast cancer. Procrit is approved by the Food and Drug 
Administration (FDA) for this indication. The records indicate that iron stores are being repleted. The criteria 
for coverage are met and the Procrit is reasonable and 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 these services have been met. Therefore, we decided that the Plan has to pre-
approve Procrit.  
 
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 pre-approve the revascularization surgery. 
 
You asked the Plan to pre-approve the surgery. You say that the services are medically necessary. The Plan 
denied your request. The Plan says the Medicare rules have not been met. 
 
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 surgery. Our physician reviewer 
found the documentation does not support the medical necessity of the treatments in question. The 
documentation does not include an assessment and rationale with a treatment plan. The documentation does not 
satisfactorily demonstrate that the enrollee will garner any benefit from the treatments in question as the enrollee has a history of spine disease and numerous portions of their complaints are not consistent with 
vasculogenic claudication. Additionally, there does not appear to be any effort documented in the records at a 
conservative treatment plan including a plan for smoking cessation or medical treatment of claudication. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the revascularization surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chiropractic services (97014, 97035) provided on April 
15, 2022, and April 20, 2022. 
 
You asked the Plan to pay for the services. You say that you need help paying this bill. The Plan denied your 
request. The Plan says these services are not covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided 
that the Plan does not have to pay for the chiropractic services (97014, 97035) provided on April 15, 2022, and 
April 20, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient hospital stay from November 
9, 2021, to November 11, 2021. 
 
You asked the Plan to waive the copayment for an inpatient hospital stay. You say that you thought the 
insurance would pay all of your hospital bill. The Plan denied your request. The Plan says the claim was 
processed 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 50% 
coinsurance for an inpatient hospital stay. However, you have only been asked to pay $670.00, which is less 
than the 50% coinsurance amount. 
 
 
 
 
 You have been asked to pay $670 for an inpatient hospital stay. An inpatient hospital stay falls within the 
Inpatient Hospital Stay 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 inpatient 
hospital stay from November 9, 2021, to November 11, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services provided on March 4, 2022. 
 
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 you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that claims should reflect where the services were 
rendered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services have not been met. Specifically, this claim was billed with the inpatient POS code. The 
records do not support that the sample was taken in an inpatient setting. The records show that this ultrasound 
was performed in the outpatient setting. Therefore, we decided that the Plan does not have to pay for ultrasound 
services provided on March 4, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on March 11, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be reconsidered. The Plan denied your 
request. The Plan says the plan is the secondary payer for these services. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has Outreaches 
were made to receive the Explanation of Benefits (EOB) from the primary payer.. As the secondary insurer, the Plan cannot be held responsible for the services until the primary insurer has denied the claim for these 
services. Therefore, we decided that the Plan does not have to pay for ultrasound services provided to the 
enrollee on March 11, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve a revascularization procedure. 
 
You asked the Plan to pre-approve the procedure. The Plan denied your request. The Plan says that this is not 
medically necessary. 
 
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 procedure. Our reviewer says that 
the requested services are considered medically reasonable and necessary in this case. Our physician reviewer 
found that the enrollee has a history of diabetes and a non-healing ulcer.  Ankle-Brachial Index (ABI) 
examinations can be unreliable in diabetics. An abnormal pulse examination is described. As the enrollee is at 
risk for limb loss without intervention, the requested procedure is medically reasonable and necessary. 
 
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 procedure have been met. Therefore, we decided that the Plan has to pre-
approve a revascularization procedure.  
 
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.