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

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on October 28, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied code is considered bundled into payment for another 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 imaging services provided to the enrollee on October 28, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine EEG provided on November 20, 2020. 
 
You asked the Plan to pay for the routine EEG. The Plan denied your request. The Plan says an intraoperative 
EEG was performed during a transforaminal lumbar epidural steroid injection. An intraoperative EEG would 
be reasonable for monitoring cerebral function only during carotid artery or intracranial vascular surgery. 
 
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 routine EEG. Our reviewer says that the 
requested routine EEG is not considered medically reasonable and necessary in this case. Our physician 
reviewer found that there is no medical need for EEG monitoring and testing during lumbar epidural injection treatment. The EEG should be denied. The lumbar injection can be safely performed without EEG testing or 
monitoring. 
 
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 routine EEG have not been met. Therefore, we decided that the Plan does 
not have to pay for a routine EEG provided on November 20, 2020.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME provided on June 28, 2021. 
 
You asked the Plan to pay for the DME. The Plan denied your request. The Plan says Original Medicare would 
be responsible for payment of all Medicare covered services related or unrelated to the members terminal 
condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the 
effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare 
also covers attending physician services and all care unrelated to the terminal illness until the first day of the 
month following the month in which hospice was revoked or discharged. 
 
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 DME provided on June 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for established patient office visit coded 99214 provided on 
September 30, 2021. 
 You asked the Plan to pay for established patient office visit. You say that you would like this claim 
reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has 
not been 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 99214 
is a column II code to column I code 64483. 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 established patient office visit coded 99214 provided on 
September 30, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81479) provided July 19, 2021 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 81479 is not supported in the medical record. Specifically, the place of service listed on 
the claim (81, lab) does not match the place of service detailed in the records (22, outpatient). Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for lab services (81479) provided July 19, 2021
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided June 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the place of service listed on 
the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based 
on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (G0482) provided June 24, 2021.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pre-approve genetic testing (0239U) provided September 24, 2021. 
 
You asked the Plan to pre-approve the genetic testing. You say that the test was medically necessary. The Plan 
denied your request. The Plan says that coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that genetic testing is covered when 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 genetic testing. Our reviewer says 
that the genetic testing was medically necessary. Our physician reviewer found the FoundationOne Liquid CDx 
test is an FDA-approved genomic test to evaluate solid tumors including colorectal cancer. NCCN currently 
recommends determination of tumor gene status for patients with metastatic colorectal cancer. The 
documentation supports that the enrollee has metastatic or advanced stage cancer, and has decided to seek 
further cancer treatment. 
 
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 genetic testing have been met. Therefore, we decided that the Plan has to 
pre-approve genetic testing (0239U) provided September 24, 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an eye exam (92015) provided November 1, 2021. 
 
You asked the Plan to pay for the eye exam. You say that the service was medically necessary. The Plan denied 
your request. The Plan says the benefit for this service was exhausted at the time the service was rendered. 
 Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers one eye exam per year. 
 
We looked at the file and the Plan's rules. The enrollee previously had an eye exam on November 1, 2021. 
Based on this information, we decided that the Plan's rules for coverage of the eye exam have not been met. 
Therefore, we decided that the Plan does not have to pay for an eye exam (92015) provided November 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (84165, 84403, 84439, 84481, 86141, 86317, 
86803, 80061, 82306, 82607, 82728, 82746, 82785, 83036, 82784) provided February 24, 2021. 
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 84165, 84403, 84439, 84481, 86141, 86317, 86803, 
80061, 82306, 82607, 82728, 82746, 82785, 83036, & 82784. 
 
We find that CPT codes 84165, 84403, 84439, 84481, 86141, 86317, 86803, 80061, 82306, 82607, 82728, 
82746, 82785, 83036, & 82784 are not supported in the medical record. Specifically, the place of service listed 
on the claim form (81, laboratory) does not match the place of service detailed in the records (11, office 
setting).  Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. 
Therefore, we decided that the Plan does not have to pay for lab services (84165, 84403, 84439, 84481, 86141, 
86317, 86803, 80061, 82306, 82607, 82728, 82746, 82785, 83036, 82784) provided February 24, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Ultrasound (76705) provided on October 14, 2021. 
 You asked the Plan to pay for code 76705. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are 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 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 the Ultrasound (76705) provided on October 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve remote monitoring of a wireless pulmonary artery 
pressure sensor for up to 30 days, including at least weekly downloads of pulmonary artery pressure 
recordings, interpretation(s), trend analysis, and report(s) by a physician or other qualified health care 
professional (93264). 
 
You asked the Plan to pre-approve remote monitoring of a wireless pulmonary artery pressure sensor. You say 
that the requested remote monitoring device is medically necessary. The Plan denied your request. The Plan 
says the requested remote monitoring device does not meet criteria. 
 
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 remote monitoring of a wireless 
pulmonary artery pressure sensor. Our reviewer says that the requested items/services are not considered 
medically reasonable and necessary in this case. Our physician reviewer found there remains a dearth of 
randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of 
CardioMEMS in patient management. As a result, at this time the CardioMEMS system would not be 
considered medically appropriate and necessary in this patients clinical management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of remote monitoring of a wireless pulmonary artery pressure sensor have not been 
met. Therefore, we decided that the Plan does not have to pre-approve remote monitoring of a wireless 
pulmonary artery pressure sensor for up to 30 days, including at least weekly downloads of pulmonary artery 
pressure recordings, interpretation(s), trend analysis, and report(s) by a physician or other qualified health care 
professional (93264).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 7, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service 
(POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on October 7, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 26, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 26, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Pulmozyme nebulizer solution. 
 
You asked the Plan to pre-approve Pulmozyme. You say that this drug is medically necessary for the enrollee's 
condition. The Plan denied your request. The Plan says this drug is not covered for the enrollees condition. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-
approved drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 Pulmozyme. Our reviewer says that this 
drug is not medically reasonable and necessary. Our physician reviewer found Continued use of Pulmozyme is 
considered not medically necessary. This patient has myotubular myopathy with quadriparesis and chronic 
respiratory failure, as well as asthma. Pulmozyme is indicated to assist with airway clearance in patients with 
cystic fibrosis (CF), where clinical studies support its effectiveness and safety. However, there is inadequate 
evidence that this drug is of benefit in patients with chronic lung diseases other than CF. Pulmozyme has been 
shown to be harmful in patients with non-CF bronchiectasis, causing reductions in lung function. There are 
other options for mucus clearance, such as nebulized saline. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Pulmozyme have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Pulmozyme nebulizer solution.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Phlebotomy services (99195) provided on June 22, 2021. 
 
You asked the Plan to pay for code 99195. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the enrollee received services (99195) while in an 
outpatient hospital setting. Per Medicare payment guidelines, code 99195 has a PC/TC indicator of 5 and payment may not be made for this code when provided to patients in an outpatient hospital setting. Therefore, 
we decided that the Plan does not have to pay for the Phlebotomy services (99195) provided on June 22, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the inpatient hospital stay provided form October 13, 2021, to October 
15, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that this should be reviewed for medical 
necessity. The Plan denied your request. The Plan says that medical necessity has not been established. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found the review has determined that the record showed that at the time of inpatient admission the 
admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier ED and/or 
observation care) would span two midnights. She was discharged home 10/15/21 when considered medically 
stable with home services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the inpatient hospital stay provided form October 13, 2021, to October 15, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on May 25, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
 
We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. 
Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 25, 2021.
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 requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
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 at the current functional level, the enrollee does not need intensive therapies, 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to 
daily therapy. The enrollee's rehab needs can be met safely at a lower intensity and alternate setting such as in a 
skilled nursing 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 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: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on June 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says there is no evidence of an established 
relationship between the member and the ordering physician. 
 
The Plan must follow Medicare rules. Medicare rules say that lab testing generally must be ordered by a 
physician who has furnished a consultation or treats an enrollee for a specific medical problem.  
  
 
 
 The file does not contain documentation of an established relationship between the enrollee and the ordering 
provider. Without a record showing that this provider is treating the enrollee, the criteria for coverage of this 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
provided on June 2, 2021.