Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 26, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. You say that you are appealing the denied claim. The Plan denied 
your request. The Plan says the rendering provider is an OON provider and there was no referral from an in-
network provider or an approved authorization. Also, the service rendered was not urgent or emergent. 
 
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 an office visit provided on January 26, 2022, by an 
out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the supplies and materials coded with code 99070 received 
on April 1, 2022. 
 
You asked the Plan to pay for the supplies and materials. You say that the services received were for transport 
services and you say that you feel these services should be covered. The Plan denied your request. The Plan 
says the claim is not payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99070 is supplies and materials (except spectacles), 
provided by the physician or other qualified health care professional over and above those usually included 
with the office visit or other services rendered (list drugs, trays, supplies, or materials provided). 
 We find that CPT code 99070 is not supported in the medical record. Specifically, an itemized bill was 
requested by the Plan and has not been provided. Without an itemized bill, this item is not payable. Based on 
this information, we decided that Medicare rules for coverage of the supplies and materials have not been met. 
Therefore, we decided that the Plan does not have to pay for the supplies and materials coded with code 99070 
received on April 1, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a three-dimensional (3D) rendering with interpretation 
and reporting (76376) and a computed tomography (CT) of the thorax (71250). 
 
You asked the Plan to pre-approve a 3D rendering and CT of the thorax. The Plan denied your request. The 
Plan says the CT of the thorax is not needed for the enrollee to be treated. The Plan also says that there are no 
records showing a detailed history why the 3D rendering is needed. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 a 3D rendering and CT of the thorax. 
Our reviewer says that a full dose diagnostic chest CT with 3D rendering is not medically necessary. Our 
physician reviewer found the enrollee has chronic obstructive pulmonary disease and is being followed with 
annual low-dose screening chest CTs. There is no justification in the clinical notes for a full dose CT or 3D 
rendering. Our reviewer found that the notes indicate the intent was to get another low-dose screening CT. Our 
physician reviewer also found that the notes do not quantify the total duration of smoking, so it is not clear the 
enrollee qualifies for low-dose cancer screening. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a 3D rendering and CT of the thorax have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a three-dimensional (3D) rendering with interpretation and reporting 
(76376) and a computed tomography (CT) of the thorax (71250).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 76604 and 99291 billed for date of service 
June 15, 2021. 
 
You asked the Plan to pay for codes 76604 and 99291. You say that these services were necessary and were 
billed appropriately. The Plan denied your request. The Plan says the medical records do not support these 
services 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, the CPT Code Manual definition of code 76604 is ultrasound, chest (includes mediastinum), real 
time with image documentation. The CPT Code Manual definition of code 99291 is critical care, evaluation 
and management of the critically ill or critically injured patient; first 30-74 minutes. 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for codes 76604 and 99291. Our reviewer says that the medical 
records do not support the services billed. Our reviewer found documentation of a chest ultrasound was not 
included in the documentation provided, and the documentation does not include information to support 30-74 minutes of critical care were provided on this date. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of codes 76604 and 99291 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure codes 76604 and 99291 billed for date of service June 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator. 
 
You asked the Plan to pre-approve portable ventilator. You say that you are appealing this denial. The Plan 
denied your request. The Plan says the denial of authorization for this device is correct, because Medicare does 
not cover ventilators used in this way and your needs could be met by a bilevel positive airway pressure 
(BiPAP) device instead. 
 
The Plan must follow Medicare rules. Medicare rules say that ventilators used to provide continuous or bilevel 
positive airway pressure (PAP) therapy, regardless of the underlying medical condition, are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-
approve a portable ventilator.
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 IRF care is needed to achieve baseline function. You 
say that you have no one to take care of you at home. The Plan denied your request. The Plan says the 
guidelines for coverage have not been met. The Plan says that the enrollee's needs cant be met at an alternate 
level of care. 
 
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. The 
enrollee was admitted for multiple myeloma, renal biopsy, hemothorax and pneumonia. The enrollee's medical 
problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require 
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive 
rehabilitation therapy program. While the medical record supports a need for physical and/or occupational 
therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be 
provided in a different level of care. 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: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a microprocessor-controlled ankle foot system (L5973) for an 
approved prosthesis. 
 
You asked the Plan to pre-approve the microprocessor-controlled ankle foot system. You say that the use of 
this ankle foot system would be beneficial for the enrollee's function and safety. The Plan denied your request. 
The Plan says that the requested type of ankle/foot system is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that microprocessor-controlled ankle foot systems such as 
L5973 may be covered for enrollees with level 3 or above functional status.  
 
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 microprocessor-controlled ankle 
foot system. Our reviewer says that the documentation supports that the requested ankle foot system is 
medically reasonable and necessary. Our physician reviewer found the beneficiary has a past medical history of 
left below-the-knee amputation and has been using an ill-fitting prosthetic. The clinical documentation shows 
that the beneficiary has the ability to ambulate on multiple surfaces with variable cadences and for long 
distances. In addition, the beneficiary has fallen forward, which supports that a microprocessor ankle/foot 
system is medically 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 microprocessor-controlled ankle foot system have been met. Therefore, we 
decided that the Plan has to pre-approve a microprocessor-controlled ankle foot system (L5973) for an 
approved prosthesis.  
 
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 pre-approve a spinal cord stimulator (SCS) trial. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that an SCS trial is covered when specific criteria 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic pain and the 
progress notes refer to complex regional pain syndrome (CRPS). She is not on Lyrica or Gabapentin and there 
is no documentation of a sympathetic block or physical therapy evaluation. The signs and symptoms support 
the diagnosis. SCS is not a first line therapy for CRPS and is not medically 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a spinal cord stimulator (SCS) trial.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for continued SNF services after August 19, 2022. 
 
You asked the Plan to pay for SNF. You say that you need continued SNF services. The Plan denied your 
request. The Plan says rules for SNF care have not been met. 
 
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care 
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and 
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
The file shows that you received 100 days of SNF care during the benefit period from March 26, 2022, to 
August 19, 2022. The Plan has covered 100 days of SNF care. 
 
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF 
coverage during this benefit period. You will be eligible for a new benefit period when you have not been 
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the 
Plan does not have to pay for continued SNF services after August 19, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Vectibix. 
 
You asked the Plan to pre-approve Vectibix. You say that the requested drug is medically necessary. The Plan 
denied your request. The Plan says no support was found for the requested use of this drug. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
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 Vectibix. Our reviewer says that the 
criteria for coverage have not been met. Our physician reviewer found the requested drug is not FDA-approved 
for the enrollee's diagnosis. The use of this drug is not supported for the enrollee's diagnosis by one of the 
major drug compendia or by clinical research that appears in a Medicare-approved medical journal. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Vectibix have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Vectibix.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laparoscopy (44213) provided on September 20, 2021. 
 
You asked the Plan to pay for the laparoscopy (44213). You say that there are no edits, and this service can be 
billed and paid separately. You say that the claim should be processed for payment. The Plan denied your 
request. The Plan says procedure code 44213 is an add-on code that was not billed with an appropriate primary 
procedure 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 44213 
is an add-on code and has not been billed with an appropriate primary procedure code. 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 laparoscopy (44213) provided on September 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bone marrow aspirate. 
 
You asked the Plan to pre-approve bone marrow aspirate. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 bone marrow aspirate. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no compelling rationale presented or extenuating circumstances noted to 
support the medical necessity of this request as an exception. Therefore, the requested bone marrow aspirate, in 
this case, is 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 bone marrow aspirate have not been met. Therefore, we decided that the Plan 
does not have to pre-approve bone marrow aspirate.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for office visit provided on December 20, 2021, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for office visit. You say that you are appealing the claim payment denial. The Plan 
denied your request. The Plan says the services were provided out-of-network and were not approved in 
advanced. 
 
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 office visit provided on December 20, 2021, by an 
out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
17, 2021. 
 
You asked the Plan to pay for procedure code 70450. You say that this service was billed appropriately and is 
supported as billed. The Plan denied your request. The Plan says payment for code 70450 is bundled into 
payment for code 70496. 
 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 procedure code 70450 billed for date of service November 17, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a targeted genomic sequence analysis panel, 51 or more 
genes (81455) provided on December 7, 2021. 
 
You asked the Plan to pay for the targeted genomic sequence analysis panel. You say that these services were 
medically necessary. The Plan denied your request. The Plan says this testing was 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 targeted genomic sequence analysis 
panel. Our reviewer says that the requested items/services are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation does not support that the coverage 
criteria for this targeted genomic sequence analysis panel have been met in this case. The Caris targeted 
genomic sequence analysis panel does not have FDA approval or FDA clearance as a companion in vitro 
diagnostic, and/or an FDA-approved or FDA-cleared indication for use in this enrollee's cancer. 
 
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 targeted genomic sequence analysis panel have not been met. Therefore, we 
decided that the Plan does not have to pay for a targeted genomic sequence analysis panel, 51 or more genes 
(81455) provided on December 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the cost sharing for the laboratory testing provided on March 
28, 2022. 
 
You asked the Plan to reduce the cost sharing for the laboratory testing. You say that you are not usually 
charged the full amount for bloodwork. You believe the Plan should pay this bill. 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. Your 
contract with the Plan says that there is a $250 deductible which applies to laboratory testing.  At the time this 
claim was processed, $0 of the $250 deductible had been met. The allowed amount of this claim is $59.95, 
resulting in a deductible amount of $59.95. 
 
The item or service you asked the Plan to reduce the cost sharing for falls within the benefit category 
Outpatient Diagnostic Tests and Therapeutic Services and Supplies. The Plan has followed Medicare rules by 
clearly disclosing in the contract that there is $250 deductible which applies to Outpatient Diagnostic Tests and 
Therapeutic Services and Supplies. This cost sharing is a contractual obligation that had not been met at the 
time the laboratory testing was received on March 28, 2022. Therefore, we decided that the Plan does not have 
to reduce the cost sharing for the laboratory testing provided on March 28, 2022.