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

 
We decided that the Plan does not have to pay for sedation services (99152) provided on March 29, 2020. 
 
You asked the Plan to pay for sedation services. You say that this is supported in the records. The Plan denied 
your request. The Plan says this is not documented. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
 
 
 
 In this case, the CPT Code Manual definition of code 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the submitted records do not 
include documentation of sedation services being administered with an independent observer present. Based on 
this information, we decided that Medicare rules for coverage of sedation services have not been met. 
Therefore, we decided that the Plan does not have to pay for sedation services (99152) provided on March 29, 
2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81238, 81286, 81410, 81411) provided April 
12, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular 
genetic risk assessment panels. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the 
Plan does not have to pay for lab services (81238, 81286, 81410, 81411) provided April 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the Eylea injections you received from 
January 18, 2021, to May 10, 2021. 
 
You asked the Plan to waive the coinsurance for the Eylea injections. You say that your previous plan did not 
charge you for this drug. You thought that these injections would be covered in full. The Plan denied your 
request. The Plan says it has waived the coinsurance for the injection you received on January 18, 2021.  
However, the Plan says that you called them on April 9, 2021, and were advised of your coinsurance 
obligation.  You then proceeded to receive two more injections after this phone call.  The Plan says that you 
were charged the coinsurance correctly for the two injections you received on April 12, 2021, and May 10, 
2021. 
 The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance for Medicare Part B drugs.  
 
You have been asked to pay 20% coinsurance for the Eylea injections. the Eylea injections fall within the 
Medicare Part B drugs benefit category. This means that you have been asked to pay the correct amount based 
on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you 
enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for the Eylea 
injections you received from January 18, 2021, to May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for wound care services (procedure code 
29580) provided on May 10, 2021. 
 
You asked the Plan to waive the copayment for the wound care. You say that surgery was not performed. You 
also say that your visit should have been billed with a different code. The Plan denied your request. The Plan 
says you have been charged the correct cost sharing amount. 
 
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 $295 
copayment for surgery services in an outpatient hospital.  
 
You have been asked to pay $131.27, which is less than the $295 copayment for surgical services. The record 
shows the services you received (procedure code 29580) are considered surgical services.  Surgical services fall within the Outpatient Hospital Services 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 wound care services (procedure code 29580) provided on May 10, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an emergency room visit (99284) provided March 16, 2021. 
 
You asked the Plan to pay for the emergency room visit. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim was not billed with a valid diagnosis 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. 
 
We find that CPT code 99284 is not supported in the medical record. Specifically, the diagnosis code billed as 
the primary diagnosis code is a secondary only code. Based on this information, we decided that Medicare rules 
for coverage of the emergency room visit have not been met. Therefore, we decided that the Plan does not have 
to pay for an emergency room visit (99284) provided March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the myocardial perfusion imaging you 
received at an out-of-network facility on July 16, 2021. 
 
You asked the Plan to waive the coinsurance for the out-of-network myocardial perfusion imaging. You say 
that no one told you that you would have 30% coinsurance.  You did not know this was an out-of-network 
provider. The Plan denied your request. The Plan says you were charged this coinsurance correctly.  The Plan 
states that you did not call prior to the services to confirm the network status of this provider. 
 
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 30% 
coinsurance for out-of-network diagnostic imaging.  
 
You have been asked to pay 30% coinsurance for the out-of-network myocardial perfusion imaging. The out-of-network myocardial perfusion imaging falls within the out-of-network diagnostic imaging benefit category. 
This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for the myocardial perfusion imaging you received at an out-
of-network facility on July 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit (99204) rendered on April 
19, 2021. 
 
You asked the Plan to waive the copayment for an office visit. You say that the provider's office took over a 
month to return calls. You also say the provider sent a bill for the $40 copayment and you refuse to pay this 
since no services from his office. The Plan denied your request. The Plan says you have been charged the 
correct cost sharing amount. 
 
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 $40 
copayment for each Medicare-covered specialist visit.  
 
You have been asked to pay a $40 copayment for an office visit. The services at issue were rendered by a 
specialist (neurologist). 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 office visit (99204) rendered 
on April 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an additional radiofrequency ablation session. 
 
You asked the Plan to pre-approve the additional session. You say that this is medically necessary. The Plan 
denied your request. The Plan says the guidelines only allow two procedures per year. 
 
The Plan must follow Medicare rules. Medicare rules say that no more than two (2) radiofrequency sessions 
will be reimbursed per rolling 12 months.  
 
The file shows that radiofrequency ablation was last received on March 4, 2021 and March 25, 2021. You 
would not be eligible to receive this service again until March 4, 2022. Based on this information, we decided 
that Medicare rules for coverage of the additional session have not been met. Therefore, we decided that the 
Plan does not have to pre-approve an additional radiofrequency ablation session.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor for the enrollee. 
 
You asked the Plan to pre-approve the monitor. You say that this is medically necessary. The Plan denied your 
request. The Plan says the evidence does not show qualification for this monitor, as there is no evidence of 
insulin use three times a day. 
 
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and 
necessary for enrollees with diabetes who meet the criteria referenced 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 the monitor. Our reviewer says that the 
requested monitor is not medically reasonable or necessary. Our physician reviewer found there is no 
indication of insulin use at least three times a day. Additionally, there is no evidence that the insulin dose is 
adjusted based on the blood glucose level readings. There is no reason given as to why the enrollee's needs 
cannot be met with finger stick glucometer checks. 
 
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 monitor have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a continuous glucose monitor for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mobile chest x-ray services provided at the patient's 
home on April 7, 2021.  
You asked the Plan to pay for the mobile chest x-ray services. You say that this was ordered by the enrollee's 
physician and was provided on an urgent/emergent basis. You feel that it is the enrollee's responsibility to 
obtain authorization, and that you should not be penalized. The Plan denied your request. The Plan says review 
of the file shows that this x-ray was provided for screening purposes and was not done due to signs/symptoms 
of disease. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal, the mobile chest x-ray services, was requested solely for tuberculosis screening. 
Medicare does not cover screening chest x-rays for tuberculosis screening. Therefore, we decided that the Plan 
does not have to pay for the mobile chest x-ray services provided at the patient's home on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded G0483 provided on February 5, 2021. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services are not payable 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 G0483 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or 
more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the 
CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The 
submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; 
however, the submitted medical documentation and/or claim history indicates that the specimen was obtained 
in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage 
of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug 
testing coded G0483 provided on February 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for lab services you received on June 5, 2021. 
 
You asked the Plan to waive the copayment for the lab services. You say that these lab services were done as 
part of your annual physical, so there should be no copayment. The Plan denied your request. The Plan says 
you were charged this copayment 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 $20 
copayment for lab services.  
 
Your Evidence of Coverage explicitly states that lab services performed as part of your annual physical exam 
are subject to separate cost sharing. You have been asked to pay a $20 copayment for the lab services. 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 lab services you received on June 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve hyperbaric oxygen (HBO) treatment.  
You asked the Plan to pre-approve HBO treatment. 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 follows Medicare rules. Medicare rules say that HBO therapy is considered medically necessary and 
reasonable for specific conditions. 
 
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 HBO treatment. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found there is no specific clinical rationale for 
the requested hyperbaric oxygen. The enrollee does not meet the coverage criteria detailed in the NCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of HBO treatment have not been met. Therefore, we decided that the Plan does not 
have to pre-approve hyperbaric oxygen (HBO) treatment.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapist on 
May 9, 2021. 
  You asked the Plan to pay for physical 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 service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that services of a physical therapist billed as services 
incident to a physician/non-physician practitioner?s service must meet all incident requirements. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner. As such, physical therapy services cannot be paid incident to this provider's professional services. 
Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical 
therapist on May 9, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a duplex scan of lower extremity arteries or arterial 
bypass grafts (93925). 
 
You asked the Plan to pre-approve the duplex scan of lower extremity arteries or arterial bypass grafts. The 
Plan denied your request. The Plan says you require an order from the treating physician with medical 
justification for the request through meeting criteria and/or medical necessity in order to obtain this service. 
 
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 duplex scan of lower extremity 
arteries or arterial bypass grafts. Our reviewer says that the duplex scan of lower extremity arteries or arterial 
bypass grafts (93925) are not considered medically reasonable and necessary in this case. Our physician 
reviewer found you have varicose veins in the bilateral lower extremities and are self-requesting a bilateral 
lower extremity ultrasound. There is no physician order for an ultrasound. Our reviewer found that the primary 
care physician (PCP) visit of July 23, 2021 includes a diagnosis of varicose veins of both lower extremities 
with pain. Notes states you need a venous reflux study to see vascular surgery and was planned for the future.  
 
  
Our reviewer found that the PCP directed you to return for an appointment and unsuccessfully attempted to 
contact you. Our physician reviewer also found that you require an order from the treating physician with 
medical justification for the request through meeting criteria and/or medical necessity in order to obtain this 
service. 
 
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 duplex scan of lower extremity arteries or arterial bypass grafts have not 
been met. Therefore, we decided that the Plan does not have to pre-approve a duplex scan of lower extremity 
arteries or arterial bypass grafts (93925).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for air ambulance transport provided to the enrollee.
You asked the Plan to pay for air ambulance transport. You say that this transport was medically necessary.
The Plan denied your request. The Plan says Medicare coverage criteria were not met. The QIC overturned the
Plans denial. The Plan requested a reopen and stated that the QIC did not apply the correct criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for air ambulance
transport. The Physician Reviewer determined that this transport was medically necessary. The Plan
argues that there is no documentation that the required services could not have been provided at the sending
hospital. The medical records show the enrollee presented to the hospital with a syncopal episode,
gastrointestinal bleeding, and hypotension. IV fluids and one unit of packed red blood cells were administered.
At the time of transport, the enrollee was awake and alert and had no complaints. Her blood pressure and heart
rate had remained stable for an hour. Our Medical Director has concluded that the Plan is correct in this case.
Medical necessity is established when a patient's condition is such that use of any other method of
transportation is contraindicated. The documentation supports that the enrollee was hemodynamically stable
prior to transport. Medicare coverage criteria for air transport were 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 air ambulance transport were not met. Therefore, we decided that the Plan does
not have to pay for air ambulance transport provided to the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services provided December 19, 2020, while out 
of the country. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says this claim is not payable without proper itemized bills and receipts. 
 
The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or 
provider must corroborate the documentation in the beneficiary's medical documentation. 
 
We looked at the file and Medicare rules. In this case, the claim is missing required information required for 
payment. There are no medical records which corroborate the services received and no itemized billing 
statement. Based on this information, we decided that Medicare rules for coverage of the medical services have 
not been met. Therefore, we decided that the Plan does not have to pay for the medical services provided 
December 19, 2020, while out of the country.