Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied 
your request. The Plan says that the coverage criteria has 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 the clinical documentation shows that the enrollee does have complex functional 
impairments however, there are no documented active medical comorbidities thus the enrollee would not be 
expected to require continued inpatient hospitalization during rehabilitation. 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 that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an office visit and cerumen removal 
provided on July 09, 2022. 
 
You asked the Plan to waive the coinsurance for an office visit and cerumen removal. You say that you feel 
you should not owe the copayment. 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 50% 
coinsurance for physician/practitioner services, including doctors office visits. 
 
You have been asked to pay 50% coinsurance for an office visit and cerumen removal. This item/service 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 coinsurance for an office visit and cerumen removal provided on July 09, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 14, 2022, billed with 
codes 81206, 81210, 812335, 81275, 81276, 81292, 81295, 81298, 81317, 81401, 81301, 81191 and 81309. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary and 
should be paid. The Plan denied your request. The Plan says panel testing should be billed using one CPT code 
on the claim. 
 
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 
January 14, 2022, billed with codes 81206, 81210, 812335, 81275, 81276, 81292, 81295, 81298, 81317, 81401, 
81301, 81191 and 81309.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99308) provided on 
March 18, 2022. 
 
You asked the Plan to pay for the nursing facility care. You say that this service should be covered. 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 subsequent nursing facility care (99308) provided on 
March 18, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the cost share for the surgeries and office visits provided on 
July 14, 2022 to August 4, 2022. 
 
You asked the Plan to waive the cost share for the surgeries and office visits. You say that you were told at 
open enrollment the provider was in-network. You also say that you should not have to pay for these claims as 
you were clearly not informed of the Plan changes. 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 $275 
copayment for in-network, and 20% coinsurance for out-of-network outpatient hospital visits.  The Plan contract also says that enrollees must pay a $50 copayment for out-of-network office and telehealth 
visits with a primary care or specialty care physician. 
 
You have been asked to pay a $275 copayment for in-network and 20% coinsurance of the allowed amount for 
out-of-network cataract surgeries provided on July 14, 2022, and August 4, 2022. You have also been asked to 
pay up to a $50 copayment for out-of-network specialist services on July 22, 2022. You have been asked to pay 
at total of $810.28.  
 
DATE OF 
SERVICE 
 
SERVICE 
ALLOWED 
AMOUNT 
 
COPAYMENT 
20% 
COINSURANCE 
July 14, 2022 66984 $2,047.31 $275.00  
July 14, 2022 66987 $536.05  $107.21 
July 22, 2022 92136 $30.14  $30.14 
July 22, 2022 92202 $15.72  $15.72 
August 4, 2022 66984 $536.05  $107.21 
August 4, 2022 66984 $2,047.31 $275.00  
TOTAL    $810.28 
 
These items/services fall within the outpatient surgery, and physician/practitioner services benefit categories. 
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 cost share for the surgeries and office visits provided on July 14, 2022 to 
August 4, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 38571 provided on March 1, 2022. 
 
You asked the Plan to pay for code 38571. You say that this was billed correctly. The Plan denied your request. 
The Plan says this is not documented. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 38571 is laparoscopy, surgical; with bilateral total pelvic 
lymphadenectomy. 
 
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 code 38571. Our reviewer says that this code is not 
supported. Our reviewer found the medical records document a left sided pelvic lyphandectomy. There is a 
more appropriate code for this service. 
 
 
 We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 38571 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 38571 provided on March 1, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve lumbar/sacral facets injections. 
 
You asked the Plan to pre-approve lumbar/sacral facets injections. You say that lumbar/sacral facets injections 
are medically necessary. The Plan denied your request. The Plan says lumbar/sacral facets injections are not 
medically necessary based on the Medicare LCD coverage criteria.  
The Plan follows Medicare 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 pre-approve lumbar/sacral facets injections. Our 
reviewer says that lumbar/sacral facets injections are not medically necessary. Our physician reviewer found 
several alternatives to percutaneous radiofrequency denervation have been proposed, including pulsed 
radiofrequency, cryoablation, laser ablation, and chemical ablation, in which a neurolytic substance (e.g., 
alcohol, phenol, glycerol) is injected into the affected nerve root. An alternative method of denervation using 
an endoscopic approach (i.e., endoscopic dorsal ramus rhizotomy) has also been proposed. There is insufficient 
evidence in the published medical literature to determine the safety and efficacy of these emerging alternative 
modalities or approaches compared to thermal radiofrequency denervation for the treatment of spinal pain. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lumbar/sacral facets injections have not been met. Therefore, we decided that 
the Plan does not have to pre-approve lumbar/sacral facets injections.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on June 17, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-
network, and it was determined these services can be received in-network. 
 
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 outpatient mental health services provided on June 
17, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve eight skilled nursing, physical therapy, and occupational 
therapy home health visits. 
 
You asked the Plan to pre-approve the visits. You say that this is medically necessary. The Plan denied your 
request. The Plan says this can only be partially approved. 
 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 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 visits. Our reviewer says that the 
requested visits are not medically reasonable or necessary. Our physician reviewer found that the enrollee does 
not have documented skilled nursing or skilled therapy needs. 
 
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 visits have not been met. Therefore, we decided that the Plan does not have 
to pre-approve eight skilled nursing, physical therapy, and occupational therapy home health visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM) monitor and 
receiver (K0554). 
 
You asked the Plan to pre-approve a CGM monitor and receiver. You say that you need the requested CGM for 
assistance with treating your diabetes. The Plan denied your request. The Plan says you do not meet coverage 
criteria for approval of the requested CGM. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM 
monitor and receiver have not been met. Therefore, we decided that the Plan does not have to pre-approve a 
continuous glucose monitor (CGM) monitor and receiver (K0554).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for anesthesia services provided to the enrollee on June 3, 2022. 
 
You asked the Plan to pay for the services. You say that this was provided at a reasonable cost. The Plan denied 
your request. The Plan says that a primary payer Explanation of Benefits was not received. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has not met its obligation with regards to coordination of benefits. Specifically, the record does not 
show that the Plan has sent the bill directly to the primary insurer for payment, directed the provider to send the 
bill to the primary insurer or paid for the services and submitted a bill for reimbursement to the primary insurer. 
Therefore, we decided that the Plan has to pay for anesthesia services provided to the enrollee on June 3, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DecisionDX-SCC test provided to the enrollee on April 
19, 2022. 
 
You asked the Plan to pay for the services. You say that there is no other laboratory in the world that provides 
this test. The Plan denied your request. The Plan says this test is not Food and Drug Administration (FDA) 
approved and is still considered 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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there are currently no indications for adjuvant therapy after resection of squamous cell cancer of the 
skin. Predicting the risk of recurrence will not ensure the benefit of the patient. Classical TMN staging is best 
way to prognosticate patient outcome. This testing is considered experimental and investigational. 
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the DecisionDX-SCC test provided to the enrollee on April 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services coded 99153 provided on 
June 10, 2022. 
 
You asked the Plan to pay for the moderate sedation services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 99153 is not supported in the medical record. Specifically, this code has a professional 
component/technical component of 3. As part of the CY 2021 Final Rule, CPT code 99153 was established as a 
practice expense-only code meaning there is no work component relative value unit (RVU) associated with that 
service. This means this claim is not payable as billed. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan 
does not have to pay for the moderate sedation services coded 99153 provided on June 10, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 26080 billed for services provided on May 
31, 2022. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says the code cannot 
be separately reimbursed. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
In this case, we have confirmed that code 26080 is a column II code to column I code 26160. The code at issue 
has not been billed with an appropriate modifier to bypass the edit. The medical records provided do not show 
that the service at issue was a distinct procedural service. Based on this information, we decided that Medicare 
rules for coverage of code 26080, billed with a -59 modifier, have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 26080 billed for services provided on May 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49010 billed for date of service April 7, 
2022. 
 
You asked the Plan to pay for procedure code 49010. You say that this should be paid for. The Plan denied 
your request. The Plan says payment for code 49010 is bundled into payment for code 50360. 
 
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 49010 
is a column II code to column I code 50360. 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 49010 billed for date of service April 7, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found based on the documentation provided, the enrollee does not qualify for SNF transfer. 
The enrollee does not have documented skilled nursing needs. The enrollee is participating in therapy at the 
current IRF. The enrollee can complete the current course of therapy before discharging to a lower level of 
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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.