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

 
We decided that the Plan does not have to reduce the coinsurance for neuropsychological services provided on 
September 14, 2021. 
 
You asked the Plan to reduce the coinsurance for neuropsychological services. You say that you thought you 
only had a $25 copayment for a specialist visit but received a bill for $48.05. 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 10% 
coinsurance for in-network non-radiological diagnostic services.  
 You have been asked to pay a total of $48.05, which is 10% coinsurance for each neuropsychological service.  
 
Code Allowed Amount 10% Coinsurance 
96138 $37.59 $3.76 
96139 $112.77 $11.28 
96116 $95.35 $9.54 
96132 $131.56 $13.16 
96133 $103.06 $10.31 
Total $480.33 $48.05 
 
Neuropsychological services fall 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 reduce the coinsurance for neuropsychological services 
provided on September 14, 2021.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for codes 81162, 81292, 81295, 81298, 81317, 81194, and 81309. We 
decided that the Plan does not have to pay for codes 81206, 81301, and 81311.  
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan says that the services are not covered as billed. 
 
We decided that the Plan has to pay for codes 81162, 81292, 81295, 81298, 81317, 81194, and 81309.  
 
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 for payment of codes 81162, 81292, 81295, 81298, 81317, 81194, and 81309. 
The Plan has not provided a valid reason to deny payment for these codes based on Medicare criteria. We find 
that the Plan has not substantiated their reasoning for the denial of payment for these codes. Therefore, we 
decided that the Plan has to pay for codes 81162, 81292, 81295, 81298, 81317, 81194, and 81309.  
 
We also decided that the Plan does not have to pay for codes 81206, 81301, and 81311. 
 
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 the various denied CPT codes are not supported in the medical record. Specifically, the testing at 
issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have 
to pay for codes 81206, 81301, and 81311. 
 
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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bed rail extensions (E1399). 
 
You asked the Plan to pre-approve bed rail extensions. You say that the bed rails are medically necessary. The 
Plan denied your request. The Plan says this item is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that side rails (E0305, E0310) or safety enclosures 
(E0316) are covered when they are required by the beneficiary's condition and they are an integral part of, or an 
accessory to, a covered hospital bed. 
 
We looked at the file and Medicare rules. The requested side rail extensions are not correctly coded as E0305 
or E0310. Based on this information, we decided that Medicare rules for coverage of bed rail extensions have 
not been met. Therefore, we decided that the Plan does not have to pre-approve bed rail extensions (E1399).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the sleeve gastrectomy (43755). 
 
You asked the Plan to pre-approve the sleeve gastrectomy (43755). You say that the surgery is necessary 
because there is a little mass that needs to be removed to avoid diseases. You say that the surgeon can send 
documentation supporting the appeal and that the procedure is medically necessary. The Plan denied your 
request. The Plan says the records do not show that you have at least one comorbidity related to obesity. 
 
The Plan must follow Medicare rules. The rules say that Medicare will cover bariatric surgery for enrollees 
who have:  
 
(1) a body mass index (BMI) of greater than or equal to 35;  
 
(2) at least one co-morbidity related to obesity; and 
 
(3) been unsuccessful with medical treatment for obesity.   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 sleeve gastrectomy (43755). Our 
reviewer says that the elements of the coverage criteria are not satisfied, and the requested service cannot be 
recommended. Our physician reviewer found that the record indicates you have morbid obesity with a body 
mass index of 34 and no significant past medical history. 
 
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 sleeve gastrectomy (43755) have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the sleeve gastrectomy (43755).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
   
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regard to the physicians intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on April 2, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on July 13, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered. 
 The Plan must follow Medicare rules. Medicare rules say that a physician order is not required to be signed, 
however, the physician must clearly document, in the medical record, his or her intent that the test be 
performed. 
   
We looked at the file and Medicare rules. We find that payment for the lab services is not supported in the 
medical record. We find that the issue of intent is not clear. There are no medical records in the case file in 
regard to the physicians intent that the test be performed prior to services taking place. Therefore, we decided 
that the Plan does not have to pay for the laboratory services provided on July 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wound care services provided on October 18, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for the wound care services provided by an OON provider. You say that you would 
like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services 
provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network 
care. 
 
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 the wound care services provided on October 18, 
2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651, E0667 ). 
 
You asked the Plan to pre-approve a pneumatic compression device. You say that this device is medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
The Plan follows Medicare rules. The rules state that a PCD is covered for the treatment of lymphedema 
extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating 
failed response. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show regular and compliant use of an 
appropriate compression bandage system or compression garment to provide adequate graduated compression 
for at least four weeks. Therefore, we decided that the Plan does not have to pre-approve a pneumatic 
compression device (E0651, E0667 ).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit. 
 
You asked the Plan to pre-approve Retacrit. You say that this drug is medically reasonable and necessary. The 
Plan denied your request. The Plan says Retacrit is not medically necessary as there has not been an evaluation 
for all other causes of anemia in this case. 
 
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. The rules also say that ESA agents are subject to 
additional coverage criteria listed 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 Retacrit. Our reviewer says that the 
requested drug Retacrit is not medically reasonable and necessary at this time. Our physician reviewer found 
the enrollee has been diagnosed with metastatic neuroendocrine tumor. Retacrit approval requires that other 
causes of anemia be tested and treated prior to initiation. This patient has evidence of iron deficiency anemia 
based on an iron saturation of 9%. This should be corrected to see if Retacrit is still needed. The service 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 Retacrit have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Retacrit.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the ambulatory surgical care, provided on 
October 6, 2021, and October 12, 2021. 
 
You asked the Plan to waive the copayment for the ambulatory surgical care. You say that the service should 
be covered. The Plan denied your request. The Plan says the cost share was 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 a $195 
copayment for outpatient surgery.  
 
You have been asked to pay a $195 copayment for the ambulatory surgical care. the ambulatory surgical care 
falls within the outpatient surgery 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 ambulatory surgical care, provided on October 6, 2021, and October 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a graft of a muscle, myocutaneous, or fasciocutaneous flap 
(15734) billed for date of service July 15, 2021. 
 
You asked the Plan to pay for a graft of muscle, myocutaneous, or fasciocutaneous flap. You say that you have 
provided records to substantiate the service billed. The Plan denied your request. The Plan says rules for 
payment have not been met because the available records do not support the service 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 15734 is "Muscle, myocutaneous, or fasciocutaneous 
flap; trunk." 
 
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 a graft of muscle, myocutaneous, or fasciocutaneous flap. 
Our reviewer says that the service at issue does not meet criteria for reimbursement.  Our reviewer found that the operative report does not describe a muscle and skin or fasciocutaneous flap from a 
donor area to the site needing repair. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a graft of muscle, myocutaneous, or fasciocutaneous flap have not been met. 
Therefore, we decided that the Plan does not have to pay for a graft of a muscle, myocutaneous, or 
fasciocutaneous flap (15734) billed for date of service July 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the bone graft services (21215, 21210). 
 
You asked the Plan to pre-approve the bone graft services. You say that these services are medically necessary 
for the enrollee's condition. The Plan denied your request. The Plan says that dental services are not covered 
according to Medicare rules. 
 
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment 
for any item or service, the information submitted by the supplier or provider must corroborate the 
documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have 
been met. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the bone graft services (21215, 21210). 
have been met. Specifically, no medical records have been submitted to verify the medical necessity of the 
requested services. Therefore, we decided that the Plan does not have to pre-approve the bone graft services 
(21215, 21210).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (0239U). 
 
You asked the Plan to pre-approve the genetic testing. You say that the procedure is medically necessary. The 
Plan denied your request. The Plan says the enrollee does not have advanced stage cancer and the testing is not 
medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is covered when the patient has either 
recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. 
 
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 genetic testing. Our reviewer says 
that this testing is not medically necessary. Our physician reviewer found molecular profiling is indicated for 
certain stages of cancer to help determine adjuvant treatment. Based on clinical staging the patient has a T2N0M0 tumor and should undergo resection. Molecular profiling would be indicated based on final 
pathological staging. The service is not yet indicated 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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pre-approve genetic testing (0239U).
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 you need IRF care. The Plan denied your request. 
The Plan says rules for IRF care have not been met. 
 
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 that you have been admitted for total knee replacement surgery Medical problems are 
stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While you have a need for physical and/or occupational therapy, there is no documentation of a need 
for an intensive rehabilitation program. In conclusion, there is not a reasonable expectation that you 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 thaat 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 pay for a transesophageal echocardiography (93313) provided on 
May 11, 2021. 
 
You asked the Plan to pay for a transesophageal echocardiography. You say that you have provided records to 
substantiate the service billed. The Plan denied your request. The Plan says rules for payment have not been 
met because the service at issue is included in another billed 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, the CPT Code Manual definition of code 93313 is "Echocardiography, transesophageal, real-time 
with image documentation (2D) (with or without M-mode recording); placement of transesophageal probe 
only." 
 
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 a transesophageal echocardiography. Our reviewer says that the service at issue does not meet criteria for reimbursement. Our reviewer found the medical record does not 
include a formal report to support that a diagnostic transesophageal echocardiography was performed. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a transesophageal echocardiography have not been met. Therefore, we decided 
that the Plan does not have to pay for a transesophageal echocardiography (93313) provided on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services (99152) provided on April 23, 
2021. 
 
You asked the Plan to pay for code 99152. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered. 
 
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 medical record does not 
contain evidence that moderate sedation was performed with the presence of an independent trained observer. 
Based on this information, we decided that Medicare rules for coverage of code 99152 have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services (99152) provided 
on April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services (97110) provided on August 24, 2021. 
 
You asked the Plan to pay for the therapy services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA 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 physical therapy have not been met. Specifically, the billing provider is a nurse practitioner, and 
not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. 
Therefore, we decided that the Plan does not have to pay for the therapy services (97110) provided on August 
24, 2021.