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

 
We decided that the Plan does not have to pay for the lab services provided on December 7, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim was 
billed without the appropriate modifier. 
 
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 payment for the billed CPT codes  is not supported in the medical record. Specifically, the billed 
codes are assigned a PC/TC indicator of 1. As such, when billed with a facility place of services, the 
professional interpretation must be billed with modifier -26 for payment to be considered. 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 the lab services provided on December 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve elevating leg rests for a manual wheelchair. 
 
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. Medicare rules say that elevating leg rests are 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 not medically necessary. Our physician reviewer found the records show that you have 
Parkinson's disease. A clinical progress note dated June 2, 2022 indicated that you need a lightweight manual 
wheelchair. The records do not support that you have a condition for which the elevating leg rests are covered. 
You are noted to have mild lower extremity swelling (edema) but it is not significant enough to require 
elevation. The elevating leg rests are not reasonable or 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 not been met. Therefore, we decided that the Plan does not 
have to pre-approve elevating leg rests for a manual wheelchair.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs Heart Failure system. 
 
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. 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the CardioMEMs was approved by the 
Food and Drug Administration (FDA) in 2014. Nonetheless, there remains a dearth of randomized, blinded 
clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient 
management. As a result, at this time the CardioMEMS system 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a CardioMEMs Heart Failure system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a partial gastrectomy and a related inpatient hospital 
admission. 
 
You asked the Plan to pre-approve a partial gastrectomy and a related inpatient hospital admission. You say 
that the records provided support the medical necessity of the requested services. The Plan denied your request. 
The Plan says the clinical value and effectiveness of gastrectomy in the setting of gastroparesis 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 a partial gastrectomy and a related 
inpatient hospital admission. Our reviewer says that the requested partial gastrectomy and related inpatient 
hospital admission are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the results of studying sleeve gastrectomy in patients are preliminary and larger studies with a longer 
follow-up are needed in both morbidly obese and non-morbidly obese patients. The surgical approach proposed 
for you may hold promise, but meets the present definition of experimental and thus is not medically necessary 
at this juncture in your care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a partial gastrectomy and a related inpatient hospital admission have not been 
met. Therefore, we decided that the Plan does not have to pre-approve a partial gastrectomy and a related 
inpatient hospital admission.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on May 10, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing identifies possible treatment options. 
The Plan denied your request. The Plan says the claim did not contain a unique identifier. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. We find that the claim was not billed with the appropriate DEX Z-Code as required. Based on this information, 
we decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided 
that the Plan does not have to pay for the gene panel testing provided on May 10, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the personal care services (T1020) provided from 
February 21, 2022, to May 14, 2022.  
You asked the Plan to reimburse you for the personal care services. You say that you did everything to make 
sure these services would be covered by insurance. You also say that the services were medically necessary. 
The Plan denied your request. The Plan says the services in this case were not certified and ordered from a 
provider. The Plan also says there were no supporting records showing medical necessity for these services. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the personal care services have not been met. Specifically, the file does not indicate that the 
services were certified or ordered by a provider. Therefore, we decided that the Plan does not have to reimburse 
you for the personal care services (T1020) provided from February 21, 2022, to May 14, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services to be provided by 
an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the OON SNF services. You say that the clinical information provided 
supports the need for SNF care. The Plan denied your request. The Plan says there are network SNF providers 
who can supply the services and care necessary. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
skilled nursing facility (SNF) services to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Zilretta. 
 
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 step therapy requirement is not met. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 knee osteoarthritis. He 
has not tried and failed the Plan's required drugs, dexamethasone and triamcinolone injections. The records do 
not show that the required drugs would be contraindicated or less effective; therefore, Zilretta 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 Zilretta.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on April 22, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says providers must 
not unbundle the services. 
 
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 gene panel was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the gene panel testing provided on April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic testing services provided on May 19, 2022. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says the rules for 
payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
 
 We find that the services at issue are not supported. Radiology and other diagnostic services furnished to 
hospital outpatients are paid under the Outpatient Prospective Payment System (OPPS) to the hospital. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the diagnostic testing services provided on May 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (01402) provided on June 15, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not 
supported. 
 
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 01402 is "Anesthesia for open or surgical arthroscopic 
procedures on knee joint; total knee arthroplasty". 
 
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 the services. Our reviewer says that the use of code 01402 is 
not supported by the records provided. Our reviewer found that the enrollee was seen on June 15, 2022, for 
post-op pain and procedure code 64447 was billed for injection for pain relief. The medical record does not 
support the use of the anesthesia code. 
 
We looked at this coder's review, the file, and Medicare rules. 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 services (01402) provided on June 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on February 5, 2022. 
 
You asked the Plan to pay for the lab services. You say that the claim does not require a modifier. The Plan 
denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We find that the enrollee was an inpatient at the time the testing services were provided. Medicare rules say 
that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. 
The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements 
made with outside providers. This service was provided via arrangement of the facility.  Payment for this service would have been included under the facility claim. Payment to you for this service is 
the responsibility of the facility. 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 the lab services 
provided on February 5, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on June 1, 2022. 
 
You asked the Plan to pay for the office visit. You say that the claim denied in error. The Plan denied your 
request. The Plan says the claim denied correctly. 
 
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 99212 
is a column II code to column I code 01402 with a modifier indicator of 0. The column II code is therefore not 
payable. Therefore, we decided that the Plan does not have to pay for the office visit provided on June 1, 2022.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for procedure code 88360 billed for date of service September 21, 2021. 
 
You asked the Plan to pay for procedure code 88360. You say that the services at issue are not inclusive to 
code 88342. The Plan denied your request. The Plan says that procedure code 88360 is included in procedure 
code 88342. 
 
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. Specifically, we determined that procedure code 88360 is the more 
comprehensive Column One code to Column Two code 88342. A Column One code cannot be bundled into a 
Column Two code. The Plan has not provided a valid denial rationale. It is the Plan's responsibility to 
substantiate its denial withe evidence. In this case, the Plan's denial has not been substantiated, so we must find 
in your favor. Therefore, we decided that the Plan has to pay for procedure code 88360 billed for date of 
service September 21, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee would benefit from long-
term acute care due to medical complexity. The Plan denied your request. The Plan says criteria for admission 
to the LTACH have not been met. The enrollee's medical needs are being met in the current acute setting. The 
LTACH would add no additional services. With additional time in the current setting, clinical stability can be 
ensured such that the appropriate lower level of care can be determined. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving care. 
 
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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for an urgent care visit on July 6, 2022. 
 
You asked the Plan to reduce the copayment for an urgent care visit. You say that you should only be 
responsible to pay a $25 copayment. The Plan denied your request. The Plan says that this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $25 copayment for in-network provider and professional 
services.  
 
The record shows you were seen at an urgent care center. The Plan says you must pay a $45 copayment for an 
urgent care visit in a specialists office. Based on the Plan contract, however, you cannot be asked to pay more 
than a $25 copayment for an urgent care visit at an urgent care center. Therefore, we decided that the Plan has 
to reduce the copayment for an urgent care visit on July 6, 2022.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on February 25, 2022. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says that the 
ambulance transportation was not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 the ambulance services. Our reviewer says 
that the requested ambulance transportation is not medically reasonable and necessary. Our physician reviewer 
found that the enrollee's presenting symptoms do not meet prudent layperson criteria for emergency care. The 
enrollee was conscious and able to speak with ALS. The documentation does not support that other means of 
transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) were contraindicated for this enrollee on February 25, 2022. The documentation does not support that the enrollee needed the 
expertise, services and lifesaving and life-sustaining equipment that only a fully equipped ambulance can 
provide for safe transport. The documentation does not support that the ambulance transport was medically 
reasonable and necessary for the enrollee. 
 
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 ambulance services have not been met. Therefore, we decided that the Plan 
does not have to pay for the ambulance services provided on February 25, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the somatic molecular panel provided on May 4, 2022. 
 
You asked the Plan to pay for the testing services. You say that the testing aids in selecting the right treatment 
options. The Plan denied your request. The Plan says providers must not unbundle services. 
 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 panel testing was not billed with a single code as required. Based on this information, we 
decided that Medicare rules for coverage of the testing services have not been met. Therefore, we decided that 
the Plan does not have to pay for the somatic molecular panel provided on May 4, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97110 billed for services provided on 
December 9, 2020. 
 
You asked the Plan to pay for the billed services. You say that the services should be honored at the in-network 
rate. The Plan denied your request. The Plan says the code remains not supported. 
 
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 97110 is therapeutic procedure, 1 or more areas, each 15 
minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 
 
 We find that CPT code 97110 is not supported in the medical record. The claim information shows that the 
services were provided in the home setting. There is a more comprehensive code available that describes home 
health physical therapy services. 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 procedure 
code 97110 billed for services provided on December 9, 2020.