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

 
We decided that the Plan does not have to pay for the ambulance services (CPT code(s): A0425 and A0429) 
provided on January 13, 2022. 
 You asked the Plan to pay for the ambulance services. You say that the claim should be paid. The Plan denied 
your request. The Plan says this is a duplicate claim for services that have already been paid. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the ambulance services have not been met. The records submitted 
do not indicate that two separate services were performed/supported. This claim appears to be a duplicate for 
date of service January 13, 2022, that was processed and paid on February 9, 2022. Therefore, we decided that 
the Plan does not have to pay for the ambulance services (CPT code(s): A0425 and A0429) provided on 
January 13, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the Prostate Cancer Assay (81542) provided on January 15, 2022, by an 
OON provider. 
 
You asked the Plan to pay for the Prostate Cancer Assay. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that prior authorization was not obtained. 
 
Medicare rules say Medicare plans must make reasonable and diligent efforts to gather and forward 
information to the Independent Review Entity (IRE). The contract with the Plan says that a referral or prior 
authorization is not required for care from out-of-network providers.  
 
The requested provider in this case is not a network provider with the Plan. The Plan contract clearly states that 
prior authorization is not required for services rendered by out-of-network providers. The Plan has not 
submitted any additional evidence to support denying the services at issue. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the Plans denial has not been substantiated so we must 
find in your favor. Therefore, we decided that the Plan has to pay for the Prostate Cancer Assay (81542) 
provided on January 15, 2022, by an OON provider.  
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for definitive drug testing (G0483) provided on August 12, 2022. 
 
You asked the Plan to pay for definitive drug testing. You say that this testing was necessary and was reported 
appropriately. The Plan denied your request. The Plan says that this service is not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of 
code G0483 is drug test(s), definitive, 22 or more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the documentation provided 
supports than more than 22 drug classes were tested, including alcohol biomarkers, alkaloids (not otherwise 
specified), amphetamines, antidepressants (serotonergic class), antidepressants (tricyclic and other cyclicals), 
benzodiazepines, buprenorphine, cannabinoids (natural), cannabinoids (synthetic), cocaine, fentayls, 
gabapentin (non-blood), heroin metabolite, methadone, methylenedioxyamphetamines, opiates, opioids and 
opiate analogs, oxycodone, phencyclidine, pregabalin, sedative hypnotics (non-benzodiazepines), tapentadol 
and tramadol. Based on this information, we decided that Medicare rules for coverage of definitive drug testing 
have been met. Therefore, we decided that the Plan has to pay for definitive drug testing (G0483) provided on 
August 12, 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) provided on 
May 20, 2022. 
 
  You asked the Plan to pay for the ultrasound of the abdominal aorta. The Plan denied your request. The Plan 
says this service is not authorized because they are not a Medicare benefit for the diagnoses listed on the claim. 
The Plan also says the records provided do not support coverage under Medicare criteria for this type of 
screening. 
 
The Plan follows Medicare rules. Medicare rules say that payment may be made for a one-time ultrasound 
screening for abdominal aortic aneurysm (AAA) for beneficiaries who meet the criteria listed in the Medicare 
rules section of this letter. 
 
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 ultrasound of the abdominal aorta. Our 
reviewer says that the criteria for coverage for the ultrasound of the abdominal aorta is not supported in the 
provided records. Our physician reviewer found the history given in the report was "nicotine dependence." Our 
reviewer found that a review of the medical records showed a history; "former smoker."  Centers for Medicare 
& Medicaid Services (CMS) requires a history of having smoked at least 100 cigarettes in a lifetime in order to 
qualify for the exam. Our physician reviewer also found that while one might assume the enrollee's history of 
"former smoker" and "nicotine dependence" would most likely mean they have smoked more than 100 
cigarettes in their lifetime, the specific information required by CMS is not present in order to qualify for 
reimbursement. 
 
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 ultrasound of the abdominal aorta have not been met. Therefore, we decided 
that the Plan does not have to pay for the ultrasound of the abdominal aorta (76706) provided on May 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the leg. 
 
You asked the Plan to pre-approve the MRI. You say that the MRI is medically necessary. The Plan denied 
your request. The Plan says the records do not show the enrollee had 6 weeks of conservative treatment. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 
necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the MRI. Our reviewer says that the 
MRI of the leg is not medically necessary. Our physician reviewer found that the enrollee with worsening left 
knee pain started on October 10, 2022, possibly from playing tennis. The enrollee has completed 8-10 sessions 
of physical therapy. Examination of the left knee was unremarkable without swelling, deformity, erythema, or 
abnormal provocative testing, however, pes anserine bursa tender. The x-ray of the left knee unremarkable, 
however, lumbar spine x-ray showing stenosis, arthropathy, and severe disc height loss. MRI of the leg was 
requested. However, although physical therapy was reported as having been completed in the past, the records 
do not show the enrollee had 6 or more weeks of conservative treatment to justify advanced imaging at this 
time. Also, the examination findings and x-ray findings suggest pes anserine bursitis and there is insufficient 
evidence from the documentation to suggest meniscal tear to justify MRI. 
 
  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 MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the leg.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 do not document chronic 
respiratory failure consequent to chronic obstructive pulmonary disease (COPD) in this enrollee. The records 
document that the home ventilator is being requested for use in average volume assured pressure support 
(AVAPS) mode with auto-titration (AE) which could be provided by a BiPAP device with AVAPS and a back-
up rate. A home ventilator is not covered by Medicare for this use.  
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 home ventilator.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 97010 billed for date of service October 20, 
2022. 
 
You asked the Plan to pay for procedure code 97010. You say that the claim should be covered. The Plan 
denied your request. The Plan says procedure code 97010 is considered bundled and not separately payable. 
 
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 97010 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 97010 is not separately payable. 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 procedure code 
97010 billed for date of service October 20, 2022.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 95938, 95957, 95861 and 
G0453. We decided that the Plan does not have to pay for the services described by procedure code(s) 95870.  
 
You asked the Plan to pay for testing services (95938, 95957, 95861, G0453 and 95870) provided on 
September 8, 2022. You say that these services were necessary and are supported as billed. The Plan says that 
the payment for code 95870 is included in the payment for code 95861. 
 
We decided that the Plan has to pay for the services described by procedure code(s) 95938, 95957, 95861 
and G0453.  
 
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, the Plan did not make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 95938, 95957, 95861 and 
G0453.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
95870. 
 
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 95870 
is a column II code to column I code 95861. 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 the services described by procedure code(s) 95870. 
 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for procedure code G2078 billed for date of service August 22, 2022. 
 
You asked the Plan to pay for the billed services. You say that the claim was billed correctly. The Plan denied 
your request. The Plan says that only an entity enrolled with Medicare as an OTP can bill these codes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. The Substance Abuse and Mental Health Services Administration 
(SAMHSA) opioid treatment program directory shows that the billing provider has been certified since 2005. 
Based on this information, we decided that Medicare rules for coverage have been met. Therefore, we decided 
that the Plan has to pay for procedure code G2078 billed for date of service August 22, 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an elective blepharoplasty of the upper and lower eyelids 
performed outside of the United States on January 11, 2022. 
 
You asked the Plan to pay for an elective blepharoplasty. You say that the service should be covered. The Plan 
denied your request. The Plan says this elective procedure perf ormed outside of the United States was not a medical emergency requiring emergency care, was not the result of a medical emergency which required 
immediate medical attention to prevent the loss of life, loss of limb, or loss of function of a limb. 
 
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that 
while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and 
pre-approved care.   
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of an elective blepharoplasty have not been met. Specifically, this procedure was not an emergency 
and could have waited until your return to the Country. Therefore, we decided that the Plan does not have to 
pay for an elective blepharoplasty of the upper and lower eyelids performed outside of the United States on 
January 11, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service October 7, 
2022. 
 You asked the Plan to pay for procedure code 76641. You say that the enrollee had multiple exams on the date 
in question. 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 for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service October 7, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for critical care, evaluation and management of the critically ill 
or critically injured patient; first 30-74 minutes (CPT code 99291-25) provided on July 17, 2022. 
 
You asked the Plan to pay for the critical care. You say that the enrollee had been treated in your emergency 
room department prior to being admitted to the hospital. You state the provider performed critical care services 
and should be compensated for the services rendered. The Plan denied your request. The Plan says the payment 
for this service is included in the fee for the procedure. 
 
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 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 critical care. Our reviewer found code 99291-25 provided 
to the enrollee on July 17, 2022, does not meet criteria for billing and reimbursement consideration. The 
medical records provided does not include sufficient information to validate billing 99291 with a 25 modifier 
for services provided on July 17, 2022. 
 
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 critical care have not been met. Therefore, we decided that the Plan does not 
have to pay for critical care, evaluation and management of the critically ill or critically injured patient; first 
30-74 minutes (CPT code 99291-25) provided on July 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
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 requested bone marrow aspirate 
remains experimental in nature. More research is needed to support its use. The services are therefore 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 bone marrow aspirate.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroid stimulating hormone (TSH) (84443) provided 
May 18, 2022. 
 
You asked the Plan to pay for the laboratory service. You say that the records provided should support the 
necessity of the service in dispute. The Plan denied your request. The Plan says this test is not covered by 
Medicare as a screening tool 
 
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 laboratory service, was requested solely for screening purposes. Medicare 
does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay 
for the thyroid stimulating hormone (TSH) (84443) provided May 18, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve inpatient psychiatric care from December 14, 2022, 
forward. 
 
You asked the Plan to pre-approve inpatient psychiatric care from December 14, 2022, forward. You say that 
the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue 
are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 inpatient psychiatric care from 
December 14, 2022, forward. Our reviewer says that you do not meet the criteria for acute inpatient mental 
health treatment beyond the date in question of December 14, 2022, forward. Our physician reviewer found 
you did not require inpatient mental health treatment beyond December 14, 2022, as you were not a danger to 
yourself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active 
treatment was taking place beyond the date in question. It did not appear that the services for the dates in 
question were reasonably expected or medically necessary to improve your condition or for the purpose of 
diagnosis. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of inpatient psychiatric care from December 14, 2022, forward have not been met. 
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from December 14, 
2022, forward.