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

 
We decided that the Plan does not have to pre-approve the ILR (CPT code 33285). 
 
You asked the Plan to pre-approve the ILR. You say that the service is necessary. The Plan denied your 
request. The Plan says the service is not 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 ILR. Our physician reviewer found insertion of an ILR would not be considered medically appropriate and necessary in this enrollee's clinical 
management. 
 
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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the ILR (CPT code 33285).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 8, 2022, billed with 
codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, 81294 81317, 81292, 81298, and 81295. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and were 
ordered by a physician. The Plan denied your request. The Plan says this claim was not billed in accordance 
with Medicare rules and does not meet criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on March 8, 2022, billed with codes 81317, 81292, 81298, 81295, 81300, 81297, 81319, 81294 81317, 81292, 
81298, and 81295.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for the insertion of a temporary bladder 
catheter provided from December 15, 2021, to January 24, 2022. 
 
You asked the Plan to waive the copayments for the catheter insertion. You say that you did not see a doctor or 
have a consultation with a doctor about your health. 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 a specialists visit.  
 
 
  You have been asked to pay a $80 copayment for the catheter insertions. The catheter insertion 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 copayments for the insertion of a temporary bladder catheter provided from December 15, 2021, to 
January 24, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 20526 billed for date of service April 18, 
2022. 
 You asked the Plan to pay for procedure code 20526. The Plan denied your request. The Plan says the number 
of units billed exceeds the maximum allowed. 
 
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 20526 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 20526 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 20526 billed for date of service April 18, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 12, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81328, 81335, 81355, 81406, 81407, 81479, 
0031U, 0032U and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says this claim was not billed in 
accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
April 12, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81238, 81291, 81306, 81328, 81335, 
81355, 81406, 81407, 81479, 0031U, 0032U and 0033U.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient hospital services rendered from December 23, 
2021, to December 25, 2021. 
 You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the submitted records do not support the billing of principal diagnosis code A41.9. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9. We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for these services. Our reviewer says that the submitted records 
do not support the billing of principal diagnosis code A41.9. Our physician reviewer found the enrollee 
presented to the hospital with a chief complaint of shortness of breath, chills, and fever. While the patient was 
acknowledged to have signs of increased heart and respiratory rates as well as white blood cell count, the 
medical record was incomplete for signs of a dysregulated response to infection. There is no documentation of 
the creatinine or bilirubin at 1.2 or higher. There is no documentation of the creatinine or bilirubin at 1.2 or 
higher. While it is noted that in the ED the patient's mean arterial pressure as 68 after admission there were no 
mean arterial pressures less than 70, there was no documented urine output less than 500 ml/day, and no 
abnormal Glasgow coma score was documented. The records do not support the billing of principal diagnosis 
A41.9.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient hospital services rendered from December 23, 2021, to December 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital services provided on February 2, 2022, to 
February 4, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for inpatient hospital services. You say that the decision to treat this patient in an 
inpatient setting was deemed medically necessary by the treating physician. The Plan denied your request. The 
Plan says the services were rendered without authorization. 
 
 
 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 requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 inpatient hospital services provided on February 2, 
2022, to February 4, 2022, by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99215), psychotherapy, 30 minutes (90833), 
and interactive complexity (90785) provided on January 6, 2022. 
 
You asked the Plan to pay for the psychotherapy services. You say that the services provided were not related 
to the enrollee's terminal condition. The Plan denied your request. The Plan says the enrollees claim would be 
covered under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of 
election until the last day of the month in which hospice is revoked.  The Plan also says it is the providers responsibility to verify the enrollees coverage before rendering services 
and to know proper billing procedures for a Medicare Advantage member on hospice. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for the office visit (99215), psychotherapy, 30 minutes (90833), 
and interactive complexity (90785) provided on January 6, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 15, 2022 billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 881241, 81291, 81306, 81328, 81355, 81335, 
81401, 0031U, 0032U, 0033U, 81479, 81407, 81406, 81238. 
 
You asked the Plan to pay for the genetic testing billed. You say that please have a look at the attachment and 
reconsider the charges which were previously denied. The Plan denied your request. The Plan says does not 
meet Medicare NCD/LCD criteria. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
February 15, 2022 billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81240, 881241, 81291, 
81306, 81328, 81355, 81335, 81401, 0031U, 0032U, 0033U, 81479, 81407, 81406, 81238.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for ambulance services provided on May 20, 
2022. 
 
You asked the Plan to waive the copayment for ambulance services. You say that this transport was an 
emergency and should be covered The Plan denied your request. The Plan says this cost sharing was charged 
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 $285 
copayment for ambulance services. 
 
You have been asked to pay a $285 copayment for ambulance services. This item/service falls within the 
ambulance 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. This copayment applies to all ambulance services, regardless of the reason.  The ambulance 
services were not denied- this amount represents the cost sharing you owe for this service. Therefore, we 
decided that the Plan does not have to waive the copayment for ambulance services provided on May 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 72193 billed for date of service May 10, 
2022. 
 
You asked the Plan to pay for procedure code 72193. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 72193 is bundled into payment for 
code 74176. 
 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 72193 
is a column II code to column I code 74176. 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 72193 billed for date of service May 10, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the brand specific Pride folding mobility scooter. 
 
You asked the Plan to pre-approve the brand specific Pride folding mobility scooter. You say that your life and 
health is in danger. You say that you need the scooter being requested due to not having balance. The Plan 
denied your request. The Plan says the records do not show documentation of medical notes that explain the 
features of the requested item that distinguish it from other available and preferred alternatives, or why the 
specific brand item requested is necessary to avoid an adverse medical outcome. 
 
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 brand specific Pride folding 
mobility scooter. Our reviewer says that the requested item is not considered medically reasonable and 
necessary in this case. Our physician reviewer found you have a past medical history of multiple comorbidities 
including gait dysfunction resulting in multiple falls. Clinical documentation shows that you meet criteria for a 
scooter, as you are unable to propel manual wheelchair or ambulate functional distances safely with walker or 
cane. However, there is no documentation to suggest that this specific brand of scooter is 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 the brand specific Pride folding mobility scooter have not been met. Therefore, 
we decided that the Plan does not have to pre-approve the brand specific Pride folding mobility scooter.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
February 1, 2022. 
 
You asked the Plan to pay for procedure codes 99601 and 99602. The Plan denied your request. The Plan says 
the billed codes are invalid 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 procedure code. 
 We find that procedure code 99601 and 99602 has a Status Indicator of I on the Physician Fee Schedule. This 
means that procedure code 99601 and 99602 is not valid for Medicare purposes. Based on this information, we 
decided that Medicare rules for coverage of procedure codes 99601 and 99602 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 99601 and 99602 billed for date of service 
February 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for medical services provided on January 6, 2022. 
 
You asked the Plan to pay for the medical services. You did not provide a specific argument with your appeal 
request. The Plan denied your request. The Plan says the member was enrolled in hospice on the date of service 
in question, so the Plan is not responsible for this bill. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for medical services provided on January 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the intracept back procedure (CPT code 64628). 
 
You asked the Plan to pre-approve the intracept back procedure. You say that this procedure fills a treatment 
gap for patients that do not receive adequate relief from traditional conservative methods. The Plan denied your 
request. The Plan says your request is not medically necessary because there is little evidence in the medical 
literature to suggest that this is an appropriate procedure for the enrollee's back pain. The Plan states it is not an 
accepted standard of medical practice for the diagnosis or treatment of back pain and it is considered 
experimental and investigational. 
 
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 intracept back procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the intracept procedure is experimental. More research is needed to show 
safety and efficacy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the intracept back procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the intracept back procedure (CPT code 64628).
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for an emergency department visit provided on November 5, 2021. 
 
You asked the Plan to pay for the emergency department visit. You say that the services were medically 
necessary. The Plan denied your request. The Plan says that the documentation submitted did not support the 
total amount billed to the Plan. 
 
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 did not provide the coding rule to support the denial. Therefore, we 
decided that the Plan has to pay for an emergency department visit provided on November 5, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939). 
 
You asked the Plan to pre-approve the bone marrow aspirate. You say that the service is medically necessary. 
The Plan denied your request. The Plan says the clinical value and effectiveness of bone marrow aspirate in the 
setting of spinal fusion surgery have not been demonstrated in the peer-reviewed literature. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found bone marrow aspirate is experimental for use as bone graft material. More research is 
needed. 
 
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 bone marrow aspirate have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the bone marrow aspirate (CPT code 20939).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the orthoses provided on April 20, 2022. 
 
You asked the Plan to pay for the orthoses. The Plan denied your request. The Plan says the documentation did 
not include a valid physician order.  
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order or relevant medical records which support medical 
necessity for the supplies provided in this case. Based on this information, we decided that the Medicare rules 
for coverage have not been met. Therefore, we decided that the Plan does not have to pay for the orthoses 
provided on April 20, 2022.