Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies (K0553), 
provided on October 25, 2021. 
 
You asked the Plan to pay for the CGM supplies. You say that the items are medically necessary. The Plan 
denied your request. The Plan says the members treating physician denies ordering these items. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid physician order. The members treating physician denies writing this order. 
The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies 
(K0553), provided on October 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the outpatient services provided on November 13, 2021. 
 
You asked the Plan to pay for the services provided. You say that the reports support the level of service. The 
Plan denied your request. The Plan says the provider did not bill as require by coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
In this case, the CPT Code Manual definition of code 70450 is computed tomography, head or brain; without 
contrast material. We find that code 70450 was billed with code 70496. CPT code 70450 may be eligible for 
payment when billed with this code pair. The claim does not show that the code at issue was billed with a 
modifier suitable for payment.  
 
The CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-
hour facility, in addition to basic service. We find that CPT code 99053 is a bundled code. When these services 
are covered, payment for them is subsumed by the payment for the services to which they are incident. Based 
on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the outpatient services provided on November 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive cardiomyopathy panel provided on July 
12, 2021. You asked the Plan to pay for the testing services. You say that the services were rendered in good faith. The 
Plan denied your request. The Plan says Medicare denies coverage for all cardiovascular genetic risk 
assessment panels. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
for screening purposes. Therefore, we decided that the Plan does not have to pay for the comprehensive 
cardiomyopathy panel provided on July 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam radiation therapy (PBRT) services. 
 
You asked the Plan to pre-approve PBRT services. You say that PBRT is a Medicare covered treatment. You 
say that the medical records provided support the need for PBRT. The Plan denied your request. The Plan says 
the requested PBRT services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve PBRT services. Our reviewer says that 
PBRT services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found whether proton therapy affords a benefit over other standard approaches (intensity-modulated radiation 
therapy and image-guided radiation therapy) for prostate cancer is an area of investigation and remains 
controversial. Particularly with the use of the SpaceOAR hydrogel spacer, the risk of gastrointestinal/rectal 
toxicity is low (since the rectum is pushed away from the prostate.) Such, it is even more unlikely that there 
would be a potential benefit from proton therapy. 
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of PBRT services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve proton beam radiation therapy (PBRT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the infectious disease detection, 22 targets (0202U) provided 
on November 3, 2021. 
 
You asked the Plan to pay for the infectious disease detection, 22 targets (0202U). The Plan denied your 
request. The Plan says multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that panels with >5 respiratory pathogens performed 
in the Part B outpatient setting are not medically reasonable and necessary.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the infectious disease detection, 22 targets (0202U) have not been met. Specifically, panels for 
more than 5 respiratory pathogens are not covered. Therefore, we decided that the Plan does not have to pay for 
the infectious disease detection, 22 targets (0202U) provided on November 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a lumbar x-ray provided on November 16, 
2021. 
 
You asked the Plan to waive the copayment for a lumbar x-ray. You say that you had the x-rays at your doctor's 
office. The Plan denied your request. The Plan says you have been charged 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 a $110 
copayment for radiological services, including x-rays at an outpatient hospital facility.  
 
The record shows you had a lumbar x-ray taken at an outpatient hospital facility. You have been asked to pay 
the allowed amount of $99.78, which is less than the $110 copayment for a lumbar x-ray.  A lumbar x-ray 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 copayment for a lumbar x-ray provided on November 16, 
2021.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the contact lens fitting (92310) provided on October 21, 2021. 
 
You asked the Plan to pay for the contact lens fitting. You say that you would like reconsideration because you 
received a routine eye exam which has a copayment of $0. The Plan denied your request. The Plan says that 
you previously exhausted your routine eyewear benefit allowance. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has not forwarded any evidence to show that you have 
exhausted your routine benefit allowance for supplemental eyewear. It is the burden of the Health Plan to 
substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find 
in your favor. Therefore, we decided that the Plan has to pay for the contact lens fitting (92310) provided on 
October 21, 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: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
May 22, 2021. 
 
You asked the Plan to pay for the evaluation and management service. You say that the medically necessary 
services were provided to the enrollee in good faith. 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 (99309) provided on May 
22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne Heme testing (81455) provided on 
August 25, 2021. 
 
You asked the Plan to pay for the FoundationOne Heme testing. You say that you would like reconsideration 
based on the records submitted. The Plan denied your request. The Plan says genetic testing procedures 
submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of 
the patient and will be denied automatically as not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the FoundationOne Heme testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee has a known diagnosis of CAL-R myeloproliferative disorder, 
further molecular testing will not impact treatment and is deemed unnecessary. 
 
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 FoundationOne Heme testing have not been met. Therefore, we decided that 
the Plan does not have to pay for the FoundationOne Heme testing (81455) provided on August 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a Transcutaneous Electrical Nerve Stimulators (TENS) 
(E0730), provided on February 4, 2021. 
 
You asked the Plan to pay for a TENS unit. You say that the item is medically necessary. The Plan denied your 
request. The Plan says the medical records do not contain documentation to support the item and the proof of 
delivery does not match the date of service. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a 
physician order and proof of delivery.  
 
The record does not contain a valid proof of delivery or relevant medical records which support medical necessity for the supplies provided in this case. The date of service and proof of delivery do not match. 
Additionally, the medical records so not support the request. The record shows that the Plan made several 
attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not 
have to pay for a Transcutaneous Electrical Nerve Stimulators (TENS) (E0730), provided on February 4, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided on April 18, 2021, through 
April 19, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like reconsideration 
because the documentation submitted supports the level of care. The Plan denied your request. The Plan says 
that the records show that outpatient care was delivered. 
 
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 record did show that at the time of inpatient admission the admitting physician reasonably 
expected that the enrollees necessary hospital care (including earlier ED and/or observation care) would span 
two midnights. 
 
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 acute inpatient hospital care provided on April 18, 2021, through April 19, 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 electrodes (A4556) provided on September 10, 2021. 
 
You asked the Plan to pay for electrodes. You say that the diagnosis code is correct. The Plan denied your 
request. The Plan says the denial of payment for this item is correct, because code A4556 has a Status Code of 
P so is bundled into the payment for the other services on this clam. 
 
The Plan must follow Medicare rules. Medicare rules say that code A4556 is a bundled code with no payment 
made for the items. If it is covered as incident to a physician service, payment for it is bundled into the payment 
for the physician service to which it is incident. We looked at the file and Medicare rules. Based on this 
information, we decided that Medicare rules for coverage of electrodes have not been met. Therefore, we 
decided that the Plan does not have to pay for electrodes (A4556) provided on September 10, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for a computed tomography (CT) scan of the 
abdomen and pelvis provided on October 26, 2021. 
 
You asked the Plan to waive the copayment for a CT scan. The Plan denied your request. The Plan says you 
have been charged 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 a $225 
copayment for advanced imaging services, including CT scans at an outpatient hospital facility.  
 
You have been asked to pay a $225 copayment for a CT scan. A CT scan 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 copayment for a computed tomography (CT) scan of the abdomen and 
pelvis provided on October 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the medical services coded 77600 provided on September 18, 
2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has been billed with an incorrect 
combination of modifiers. 
 
The Plan must follow Medicare rules. The rules state that providers should bill either a -59 modifier or a -XU 
modifier, but not both together. In this case, you have billed both a -59 and a -XU modifier on the same 
procedure code. Therefore, we decided that the Plan does not have to pay for the medical services coded 77600 
provided on September 18, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the non-emergency ambulance transportation provided on 
September 3, 2021. 
 
You asked the Plan to pay for the non-emergency ambulance transportation. You say that if the Plan covered 
the hospital stay and the rehabilitation facility, you feel that the ambulance transportation should also be 
covered. The Plan denied your request. The Plan says this claim was processed correctly. The Plan also says 
that non-emergent transportation to a rehabilitation facility is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the non-emergency ambulance 
transportation provided on September 3, 2021 have been met. The documentation provided did not include any 
medical records for this case. Therefore, we decided that the Plan does not have to pay for the non-emergency 
ambulance transportation provided on September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-care services provided January 26, 2021, through 
August 4, 2021, rendered by a personal trainer. 
 
You asked the Plan to pay for the self-care services. You say that you would like these multiple claims 
reprocessed and approved for payment. The Plan denied your request. The Plan says services provided by a 
personal trainer are not covered by Medicare. 
 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. 
 
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare 
program. Therefore, we decided that the Plan does not have to pay for the self-care services provided January 
26, 2021, through August 4, 2021, rendered by a personal trainer.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to provide additional payment for the ophthalmological services: medical 
examination and evaluation, with initiation or continuation of diagnostic and treatment program; 
comprehensive, established patient (92014) provided August 11, 2021. 
 
You asked the Plan to provide additional payment for the medical eye exam. You say that the exam was a post-
surgery wellness check. The Plan denied your request. The Plan says that the claim was paid correctly. 
 
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. In this case the Plan has not provided their Evidence of Coverage (EOC) to 
review whether the claim was categorized correctly and the copayment applied appropriately. The EOC was 
requested on March 18, 2022, and still not received. Therefore, we decided that the Plan has to provide 
additional payment for the ophthalmological services: medical examination and evaluation, with initiation or 
continuation of diagnostic and treatment program; comprehensive, established patient (92014) provided August 
11, 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 the medical services coded 77600-59-XU provided on 
October 8, 2021. 
 
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says you billed with an incorrect combination of 
modifiers. 
 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 77600-59-XU is not supported in the medical record. The rules state that providers 
should bill either a -59 modifier or a -XU modifier, but not both together. In this case, you have billed both a -
59 and a -XU modifier on the same procedure code. Based on this information, we decided that Medicare rules 
for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to 
pay for the medical services coded 77600-59-XU provided on October 8, 2021.