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

 
We decided that the Plan does not have to pay for endoscopy services represented by code 43239. 
 
You asked the Plan to pay for code 43239. You say that you billed according to CMS guidelines and should get 
paid for both procedures. You say that the attached operative and pathology report mentioned that a dilation 
was performed with an EGD with biopsy. The Plan denied your request. The Plan says the criteria for coverage 
of the code in dispute have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that if Field 21 contains an indicator of 3, and 
multiple endoscopies are billed, the special rules for multiple endoscopic procedures apply. 
 
We looked at your request, the file and Medicare rules. Based on this information we have determined that 
Medicare criteria for coverage have not been met. Specifically, the codes at issue on this claim have an 
indicator of 3 and the same base endoscopy code. The record clearly indicates that the Plan paid the full value 
of the highest valued endoscopy, plus the difference between the next highest and base endoscopy. Therefore, 
we decided that the Plan does not have to pay for endoscopy services represented by code 43239.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcranial magnetic stimulation (TMS) therapy. 
 
You asked the Plan to pre-approve TMS therapy. You say that this treatment is medically necessary for treating 
the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been 
met. 
 
The Plan must follow Medicare rules. Medicare rules say that transcranial magnetic stimulation retreatment 
may be considered for patients who met the guidelines for initial treatment and subsequently developed relapse 
of depressive symptoms if the patient responded to prior treatments as evidenced by a greater than 50% 
improvement in standard rating scale measurements for depressive symptoms or if there were a relapse after 
remission. 
 
We looked at the file and Medicare rules. In this case, the documentation shows the enrollee previously 
received TMS therapy. There is no evidence that the enrollee experienced any positive benefits as the record 
indicates prior TMS (2019, 40 sessions) w/ minimal to no benefit. Based on this information, we decided that 
Medicare rules for coverage of TMS therapy have not been met. Therefore, we decided that the Plan does not 
have to pre-approve transcranial magnetic stimulation (TMS) therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for evaluation and management services provided on December 
28, 2021, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the OON evaluation and management services. You say that authorization was 
not obtained prior to seeing the enrollee because it is the nursing facility's responsibility to get authorizations 
for their patients. You say that the authorization the nursing facility is supposed to obtain should cover the 
skilled nursing and also medical treatments provided by the doctor in this case. You say that it was medically 
necessary for the enrollee to receive the services in dispute. The Plan denied your request. The Plan says the 
OON services provided were not urgent, emergent, or approved in advance. 
 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 evaluation and management services provided on 
December 28, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the percutaneous vertebral augmentation. 
 You asked the Plan to pre-approve the percutaneous vertebral augmentation. You say that the service is 
medically necessary. The Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that the plan must cover what Medicare covers. Services 
that are not medically necessary are not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the percutaneous vertebral 
augmentation. Our reviewer says that the service is not medically necessary. Our physician reviewer found the 
magnetic resonance imaging (MRI) shows fragment retropulsion which is a contraindication for cement 
augmentation. 
 
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 percutaneous vertebral augmentation have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the percutaneous vertebral augmentation.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unlisted ambulance service (A0999) provided on August 
23, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that there were 2 ambulance that shows up. You 
say that the second one that showed up only talked to the other paramedics and not you. You also say that you 
do not feel that you should have to pay this bill. The Plan denied your request. The Plan says since there was no 
transport provided, there is no payable service. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on August 23, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the unlisted ambulance service (A0999) provided 
on August 23, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the skilled nursing facility (SNF) care to be provided by 
a network facility. 
 
 
 
 You asked the Plan to pre-approve the SNF care. You say that you have fallen and cannot walk or be alone. 
You say you do not have someone who is able to care for you at home while you recover. The Plan denied your 
request. The Plan says authorization denied because SNF care is not medically necessary and your needs can be 
met at a lower level of care such as home with home health, in residential care, or home with close follow-up 
with your doctor. 
 
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 the SNF care. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found you do not have documented skilled 
nursing needs. You do not have documented skilled therapy needs. You appear to be functioning at/near your 
baseline. Daily skilled services are not required to establish a maintenance program or to prevent deterioration 
of your condition. Your care needs, custodial and intermittent, can, as a practical matter, be provided at a lower 
level of care (ex. home, assisted living, long-term 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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the skilled nursing facility (SNF) care to be provided by a network facility.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on September 15, 2021. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says these services are 
not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab services as they are considered part of the composite rate. 
No other payment for these services is allowed. Therefore, we decided that the Plan does not have to pay for 
the lab services provided on September 15, 2021.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pay for glucose monitor supplies (K0553) provided on November 29, 2021. 
 
You asked the Plan to pay for glucose monitor supplies. You say that the requirements for coverage have been 
met. The Plan denied your request. The Plan says that a valid proof of delivery or a delivery ticket indicating 
the specific supplies has not been submitted. 
 
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. Although the Plan states that a proof of delivery was not submitted, the 
submitted records include an itemized delivery ticket that was signed by the enrollee. The Plan has not 
provided information indicating why this proof of delivery is not valid. Therefore, we decided that the Plan has 
to pay for glucose monitor supplies (K0553) provided on November 29, 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 stay is medically necessary. The Plan 
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. 
 
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 patient appears to be more stable and improving and should only require short-
term additional acute care services that can be safely completed at the current facility until more appropriate for 
a lower level of care. The patient does not require services at the LTACH that are not already available at the 
current facility. 
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to remove the cost share amount for the self-administered drugs 
provided in an outpatient setting from August 5, 2021, to August 7, 2021. 
 
You asked the Plan to remove the cost share amount for the self-administered drugs. You say that the services 
should be covered. The Plan denied your request. The Plan says the drugs you received are considered self-
administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug 
plan. The Plan also says the drugs you received are not covered under Medicare Part B. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to remove the cost share amount for the 
self-administered drugs provided in an outpatient setting from August 5, 2021, to August 7, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the personal care services (T1019) provided from January 4, 
2022, through January 20, 2022. 
 
You asked the Plan to pay for the personal care services. You say that these services should be covered for the 
enrollee based on their medical situation. The Plan denied your request. The Plan says custodial care is not 
covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered.  
 
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, we find that the services at issue in this 
case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for the 
personal care services (T1019) provided from January 4, 2022, through January 20, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the head or brain 
(70450) provided on January 23, 2022. 
 
You asked the Plan to pay for a CT scan of the head or brain. You say that you have provided records to 
support the level of service. The Plan denied your request. The Plan says rules for payment have not been met 
because the CPT code at issue is inclusive to 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, we have confirmed that code 70450 
is a column II code to column I code 70496. 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 a computed tomography (CT) scan of the head or brain (70450) 
provided on January 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the elbow orthosis (L3761) provided December 21, 2021. 
 
You asked the Plan to pay for the orthosis. You say that please review the attached medical records. The Plan 
denied your request. The Plan says evidence of misrepresented services. 
 The Plan must follow Medicare rules. Medicare rules say that for eligible telehealth services, 
telecommunications systems substitute for an in-person encounter. Medicare enrollees are eligible for 
telehealth services only if they are presented from an authorized originating site located in either a county 
outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional Shortage Area (HPSA) located 
in a rural census tract. 
  
There is no evidence of an established relationship between the enrollee and the ordering physician, there was 
no claims submitted for an evaluation and management service and there is no evidence of a prior telehealth 
service with the ordering physician as required per CMS guidelines. A review of the file does not show that the 
telehealth service was provided in an authorized originating site. This means that the telehealth visit is not a 
covered service under the Medicare program and cannot substitute for an in-person encounter. Consequently, 
the items/services ordered following the noncovered visit are likewise noncovered. Therefore, we decided that 
the Plan does not have to pay for the elbow orthosis (L3761) provided December 21, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve carpet cleaning received on November 5, 2021. 
 
You asked the Plan to pre-approve the cleaning. You say that this was medically necessary due to lung disease. 
The Plan denied your request. The Plan says the request is not a covered benefit because carpet cleaning does 
not diagnose or treat your condition or improve the function of a malformed body member. 
 
The Plan must follow Medicare rules. Medicare rules say that plans must pay for a medical service or item if 
regular Medicare would pay for it. 
 
We looked at the file and Medicare rules. Carpet cleaning is not an inherently medical service that Medicare 
would pay for. Based on this information, we decided that Medicare rules for coverage of the cleaning have not 
been met. Therefore, we decided that the Plan does not have to pre-approve carpet cleaning received on 
November 5, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a seat lift mechanism. 
 
You asked the Plan to pre-approve seat lift mechanism. You say that the item is medically necessary. The Plan 
denied your request. The Plan says the item is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions 
listed in the Medicare rules section 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 seat lift mechanism. Our reviewer says 
that the item is not medically necessary. Our physician reviewer found the provided medical records do not 
show that a seat lift is included in the treating practitioner's course of treatment or that it is likely to: (a) effect 
improvement in the patient's condition; or (b) arrest or retard deterioration in the patient's condition. The 
records also show that the member is able to get out of a chair or bed with limited to no assistance and once standing has the ability to ambulate. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of seat lift mechanism have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a seat lift mechanism.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services coded with 96732, 97016, 97112, 
G0283, J1955, J3411, J3415 and J3490 provided on June 16, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the outpatient services. You say that please review the documents and reprocess 
this claim for payment. The Plan denied your request. The Plan says enrollees must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered. 
 
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 outpatient services coded with 96732, 97016, 
97112, G0283, J1955, J3411, J3415 and J3490 provided on June 16, 2021 by an out-of-network (OON) 
provider.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on September 3, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 69990 and 76000 are 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 CPT code. In this case, we have confirmed that code 69990 
is a column II code to column I code 22551 with a modifier indicator of 0. The column II code cannot be paid 
separately. 
 
Code 76000 is a column II code to column I code 22551 with a modifier indicator of 1. The column II code was 
not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does 
not have to pay for the surgical services rendered on September 3, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Guardant360 testing (0242U) provided on August 30, 2021. 
 
You asked the Plan to pay for Guardant360 testing. You say that this was billed correctly. The Plan denied your 
request. The Plan says this was not billed with the correct POS. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for Guardant360 testing (0242U) provided on August 30, 2021.