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

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 
16, 2021. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for this code is bundled into payment for 
another code 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, we have confirmed that code 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service November 16, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the remote after loading high dose rate 
radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed (77771) and 
the therapeutic radiology simulation-aided field setting (77280) provided on October 12, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the services provided. 
 
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 20% 
coinsurance per visit for radiation therapy.  
 
 You have been asked to pay $173.64 (Plan allowed amount of $868.21 x 20% coinsurance) for the radiation 
therapy services provided. 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 the remote after loading 
high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when 
performed (77771) and the therapeutic radiology simulation-aided field setting (77280) provided on  
October 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the limited ultrasound of the abdomen (76705) provided on 
October 23, 2021. 
 
You asked the Plan to pay for the limited ultrasound. You say that the enrollee had multiple exams on this date. 
The Plan denied your request. The Plan says a National Correct Coding Initiatives (NCCI) Procedure to 
Procedure (PTP) edit exists between 76700 and 76705.  
 This PTP edit has a modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an 
appropriate modifier was not billed with this PTP code edit. This service was not billed as required by 
Medicare coding regulations. 
 
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 76705 
is a column II code to column I code 76700. 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 limited ultrasound of the abdomen (76705) provided on 
October 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for a bortezomib injection (J9041) provided 
from March 4, 2021, to March 31, 2021. 
 
You asked the Plan to waive the coinsurance for the bortezomib injection. You say that the services should be 
covered. The Plan denied your request. The Plan says the coinsurance applied correctly based on the services 
provided. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs and the administration of them.  
 
 
  You have been asked to pay a 20% coinsurance for bortezomib injections (total allowed is $6,256.8 x 20% = 
$1,251.36). Bortezomib injections fall within the Medicare Part B prescription drugs 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 a bortezomib injection (J9041) provided from March 4, 
2021, to March 31, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral transforaminal epidural steroid injections. 
 
You asked the Plan to pre-approve TFESI services. You say that you need this injection as you have shown 
recent improvement. The Plan denied your request. The Plan says this benefit is limited to four injections per 
rolling 12-month period. 
 
The Plan must follow Medicare rules. Medicare rules say that ESIs are limited to a maximum of four sessions 
per spinal region. 
 
We looked at the file and Medicare rules. In this case, the documentation indicates that you have already 
received four sessions per rolling 12-month period. Based on this information, we decided that Medicare rules 
for coverage of TFESI services have not been met. Therefore, we decided that the Plan does not have to pre-
approve bilateral transforaminal epidural steroid injections.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee will benefit from improving to a safe 
functional level of mobility and activities of daily living. The Plan denied your request. The Plan says the 
denial of authorization for IRF service is correct. 
 
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 the complexity of the enrollee's nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the 
enrollee may need physical and/or occupational therapy, there is no documented need for an intensive 
rehabilitation therapy program. There is not a reasonable expectation that the enrollee will be able to fully 
participate in - and benefit from - the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the services (CPT code 88342-TC) provided on September 3, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the service is not covered as billed. 
 
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. We see absolutely no indication as to why using the TC modifier is inappropriate 
and the Plan did not elaborate why this service should not be covered. The rules and other information the Plan 
sent did not substantiate why this service is not covered as billed. Therefore, we decided that the Plan has to 
pay for the services (CPT code 88342-TC) provided on September 3, 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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for radiation therapy provided by a network 
provider on October 14, 2021. 
 
You asked the Plan to waive the coinsurance for the radiation therapy. You say that you were not informed 
there would be any cost associated with treatment besides an office visit copayment. The Plan denied your 
request. The Plan says you have been asked to pay the correct cost-sharing amount. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 20% 
coinsurance per visit for radiation therapy.  
 
You have been asked to pay $347.28 which is 20% of the allowed amount for the radiation therapy. The 
allowed amount is $1,736.42. ($1,736.42 x 20% = $347.28). The radiation therapy falls within the Outpatient 
diagnostic tests and therapeutic services and supplies benefit category.  
 This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost 
sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that 
the Plan does not have to waive the coinsurance for radiation therapy provided by a network provider on 
October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the special anesthesia service rendered on May 11, 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 the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is 
always bundled into payment for other services not specified. 
 
We looked at the file and Medicare rules. Billed procedure code 99100 (special anesthesia service) has a status 
indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for 
the special anesthesia service rendered on May 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) at L5-S1. 
 
You asked the Plan to pre-approve the repeat ESI. You say that the enrollee had excellent pain relief for six 
weeks, but then pain began to return. As such, a repeat ESI is needed. The Plan denied your request. The Plan 
says the documentation does not support that the enrollee had 50% pain relief for at least three months. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat ESI when the first injection directly and 
significantly provided improvement of the condition being treated may be considered medically reasonable and 
necessary when a prior injection produced at least 50% pain relief for three months or more. 
 
In this case, the last ESI was provided on December 2, 2021. Though this produced 80% pain relief, the repeat 
injection was requested before three months had passed. Repeat injection cannot be approved without 
documentation that the pain remains 50% reduced for three months. Therefore, we decided that the Plan does 
not have to pre-approve a repeat epidural steroid injection (ESI) at L5-S1.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory service (CPT code 83970) provided on 
October 6, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the Medicare rules have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The documentation submitted by the laboratory failed to show that the laboratory tests reported were unrelated to treatment of ESRD. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory service 
(CPT code 83970) provided on October 6, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 8 additional physical therapy sessions. 
 
You asked the Plan to pre-approve 8 additional physical therapy sessions. You say that you require additional 
therapy to regain your mobility and strength in your hand. The Plan denied your request. The Plan says the 8 
additional PT sessions are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
 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 8 additional physical therapy sessions. 
Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent 
deterioration of your condition. Our physician reviewer found that based on the medical records provided there 
is no documentation that the requested therapy is generally accepted as specific and effective therapy for your 
condition. There is no documentation that the unique skills of a professional therapist are required to safely and 
effectively provide treatment, that the services can be safely and effectively performed only by a therapist or 
under the supervision of a therapist. There is also no documentation that the specialized skill, knowledge and 
judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your 
current condition or to prevent or slow further deterioration. Based on the available records you appear to have 
plateaued with therapy; the last therapy note reports "everything is about the same." Further skilled therapy at 
this point does not appear to be medically necessary to achieve significant improvement in your symptoms or 
functional status. After completion of 23 physical therapy sessions, further utilization of the home exercise 
program appears appropriate at this point. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of 8 additional physical therapy sessions have not been met. Therefore, we decided 
that the Plan does not have to pre-approve 8 additional physical therapy sessions.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Motegrity. 
 
You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your 
request. The Plan says that this is not covered under 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 pre-approve Motegrity.  
 
 
 Benefits for this drug 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the WATS 3D Biopsy provided on May 24, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says your request does not meet Medicare rules because a review of the medical literature and clinical 
practice guidelines does not support the clinical utility of this testing, including computer-assisted 
immunohistochemistry, to predict cancer. 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found WATS-3D brush biopsy for Barrett's esophagus is investigational/not clinically proven and, 
therefore, not medically necessary. Limitations No limitations were identified during the writing of this policy. 
Alternative covered services: Conventional biopsy. The review has determined that the items/services at issue 
in this case are not medically reasonable or 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 the service have not been met. Therefore, we decided that the Plan does not 
have to pay for the WATS 3D Biopsy provided on May 24, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on October 12, 2021. 
 
You asked the Plan to pay for the lab services. You say that this is a separate service. The Plan denied your 
request. The Plan says the lab tests are not separately reportable. 
 
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 October 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ECG (93010) provided on May 29, 2021. 
  You asked the Plan to pay for the ECG (93010). You say that CPT code 93010 is separately payable when 
modifier XE is appended. You say that the attached supporting documentation should be reviewed, and the 
claim processed for payment. The Plan denied your request. The Plan says this charge is a duplicate of an 
allowed charge submitted by another provider for the same service. 
 
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined 
to be an exact duplicate are rejected and do not have appeal rights.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the ECG (93010) have not been met. Therefore, we decided that the Plan does not have to pay for 
the ECG (93010) provided on May 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT, head or brain; without contrast material (CPT code 
70450) provided on November 29, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is not covered 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, 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 CT, head or brain; without contrast material (CPT code 70450) 
provided on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for the remote after loading high dose rate 
radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed (77771), the 
special radiation dosimetry (77331), and the therapeutic radiology simulation-aided field setting (77280) 
provided on October 11, 2021. 
 
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to 
the services provided. 
 
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 20% 
coinsurance per visit for radiation therapy.  
 You have been asked to pay $186.45 (Plan allowed amount of $932.25 x 20% coinsurance) for the radiation 
therapy services provided. 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 the remote after loading 
high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when 
performed (77771), the special radiation dosimetry (77331), and the therapeutic radiology simulation-aided 
field setting (77280) provided on October 11, 2021.