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

 
We decided that the Plan does not have to pay for the hospital discharge day management services (99238) 
provided on October 20, 2021. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that you would like 
reconsideration based on the records submitted. The Plan denied your request. The Plan says the member was 
enrolled in hospice on the billed date of service. 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 hospital discharge day management services (99238) 
provided on October 20, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Cologuard colorectal screening (81528). 
 You asked the Plan to pre-approve a Cologuard test. You say that this test is necessary to determine if the 
enrollee requires a repeat colonoscopy. The Plan denied your request. The Plan says the criteria for Medicare 
coverage of a Cologuard test are not met in this case, and therefore this service is not medically necessary and 
reasonable. 
 
The Plan must follow Medicare rules. Medicare rules say that a Cologuard test is covered once every three 
years for Medicare beneficiaries who meet all of the following criteria: age 50 to 85 years, asymptomatic, and 
are at average risk of developing colorectal cancer. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of a Cologuard test have not been met. Specifically, the enrollee is not within the age range required 
for coverage of this test, and this test is requested due to a change in the enrollees symptoms. Therefore, we 
decided that the Plan does not have to pre-approve a Cologuard colorectal screening (81528).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Fasciotomy (26045-59, F8) provided on November 12, 
2021. 
 
You asked the Plan to pay for code 26045-59, F8. You say that you would like the Plan to reconsider their 
denial. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 26045 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 
26045-59, F8 have not been met. Therefore, we decided that the Plan does not have to pay for the Fasciotomy 
(26045-59, F8) provided on November 12, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for fluoroscopic guidance for needle placement (77002) 
provided on December 6, 2021. 
 
You asked the Plan to pay for fluoroscopic guidance for needle placement. You say that this service is 
supported in the medical records. The Plan denied your request. The Plan says this is an add-on code which 
was billed without an appropriate primary procedure. 
 
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 
fluoroscopic guidance for needle placement 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 fluoroscopic guidance for needle placement (77002) provided 
on December 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an office visit on January 26, 2022. 
 
You asked the Plan to waive the copayment for an office visit. You say that you would like to appeal the cost 
share and that this was your annual wellness exam. The Plan denied your request. The Plan says after the 
review of the medical records for this office visit, an endometrial biopsy procedure was performed in addition 
to the anticipated wellness exam which falls out of the wellness or preventative visit criteria. 
 
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 $30 
copayment for an office visit.  
 
You have been asked to pay a $30 copayment for an office visit. an office visit falls within the 
Physician/Practitioner services, including doctors office visits 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 an office visit on January 26, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Panniculectomy (15830). 
 
You asked the Plan to pre-approve a Panniculectomy (15830). You say that the requested Panniculectomy 
(15830) is medically necessary. The Plan denied your request. The Plan says the requested Panniculectomy 
(15830) is 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 a Panniculectomy (15830). Our 
reviewer says that the requested Panniculectomy (15830) is not medically necessary. Our physician reviewer 
found the record indicates that the enrollee wishes to have abdominoplasty.  The record provided supports that 
this procedure is for cosmetic purposes. The record provided does not establish the medical necessity and 
reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria 
are not satisfied.  The requested service is not recommended. 
 
 
 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 Panniculectomy (15830) have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a Panniculectomy (15830).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have waive your copayments for an office visit and barium swallow on 
September 23, 2021. 
 
You asked the Plan to waive your copayment for an office visit and barium swallow performed on September 
23, 2021. You say that at the time of service you were told you did not have a copayment, and this would be 
covered in full by your insurance. The Plan denied your request. The Plan says you must pay a $35 copayment 
for services obtained from a specialist. The Plan also says you must pay a $125 copayment for Medicare-
covered radiological diagnostic services. 
 
 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 $35 
copayment for Physician/Practitioner Services, Including Doctors' Office Visits. Your contract with the Plan 
also clearly says that you must pay a $125 copayment for a barium swallow. 
 
You have been asked to pay a $35 copayment for an office visit. An office visit falls within the 
Physician/Practitioner Services, Including Doctors' Office Visits benefit category. You have also been asked to 
pay a $125 copayment for a barium swallow. A barium swallow 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. Your total responsibility for these services is $160 
($35+$125).  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 waive your copayments for an office visit and barium 
swallow performed on September 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for multianalyte Assay (0013M) provided November 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that Cxbladder Monitor provides actionable 
results that can make a meaningful difference in the diagnosis and treatment of the enrollee. As a urine-based 
test, Cxbladder monitor provides the information necessary to make informed decisions. The Plan denied your 
request. The Plan says this service does not meet Medicare's criteria of being medically reasonable and 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Additional studies are needed to support the use of Cxbladder Detect 
test. This test has not been evaluated by the MolDx Programs technical assessment process and LCD 35396 
cites it as noncovered. 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 multianalyte Assay 
(0013M) provided November 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on March 
25, 2021. 
 
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. 
The Plan denied your request. The Plan says the services billed are not supported by the documentation. 
 
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 codes 80307 and G0483 are not supported in the medical record. Specifically, the place of 
service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was 
obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of 
service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was 
obtained in office setting place of service 11. In addition, the laboratory results submitted indicate the specimen 
was collected on March 25, 2021 and received by the lab on March 29, 2021. Based on this information, we 
decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the drug testing coded 80307 and G0483 provided on March 25, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRA of the abdomen with and without contrast (CPT 74185). 
 
You asked the Plan to pre-approve an MRA of the abdomen with and without contrast. You say that an MRA is 
medically necessary. The Plan denied your request. The Plan says that an MRA is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRAs 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 an MRA of the abdomen with and 
without contrast. Our reviewer says that an MRA is medically necessary. Our physician reviewer found that 
while the enrollee has had a recent CT in March of 2022, it was done without contrast material.  Importantly 
she has a past history of splenic infarction and splenic vein thrombosis. She also has a history of 
pancreatitis. While the requested MRA of the abdomen will likely be a low yield procedure, the worrisome 
historical point is her prior splenic infarction and splenic vein thrombosis. Given these historical facts it is 
prudent to perform a non-invasive mesenteric blood flow assessment and the requested MRA of the abdomen 
will be of significant value even if negative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRA of the abdomen with and without contrast have been met. Therefore, 
we decided that the Plan has to pre-approve an MRA of the abdomen with and without contrast (CPT 74185).  
 
 
 
 
 
 
 
 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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pre-approve a crown (D2751) for tooth #7. 
 
You asked the Plan to pre-approve the crown. You say that you would like to appeal this service because you 
need it. The Plan denied your request. The Plan says that there is not enough tooth remaining to put a crown on. 
The Plan also says that the prognosis for this tooth is poor. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers the crown 
when the services are medically necessary and reasonable. 
 
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 crown. Our reviewer says that the 
documentation provided meets the criteria for a crown restoration (D2751) for tooth #7. Our physician 
reviewer found the documentation indicates that tooth #7 has fractured across the crown. Our reviewer also 
found that the bone support appears adequate, and a crown placement is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of the crown have been met. Therefore, we decided that the Plan has to pre-
approve a crown (D2751) for tooth #7.  
 
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: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental services you received from an out-of-network dentist 
from April 26, 2021, to November 17, 2021. 
 
You asked the Plan to pay for the out-of-network dental services. You say that you were not aware that this 
dentist was out-of-network because you had been going there for years.  You said that no one ever told you this 
provider wasn't in the network. The Plan denied your request. The Plan says dental services you receive from 
out-of-network providers are not covered.  The Plan also says that two of the services you received (periodontal 
maintenance and the fluoride treatment) are not covered services under your dental plan, regardless of the 
network status of the dentist. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan's dental benefit does 
not cover out-of-network services.  The dentist you saw is out-of-network.  It is the enrollee's obligation to confirm 
the provider's network status prior to receiving services. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for dental 
services you received from an out-of-network dentist from April 26, 2021, to November 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve LTACH services. You say that the enrollee is stable and suitable for transfer 
to an LTACH. The Plan denied your request. The Plan says the enrollee is receiving appropriate inpatient care 
at the current hospital and can remain there until ready for discharge to a lower level of care such as in a skilled 
nursing facility. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there are no services at the LTACH that the enrollee requires that is not already 
available and covered at the current facility. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH 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. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not medically necessary. Our physician reviewer found you were admitted to 
the hospital with a urinary tract infection and a pressure ulcer that required antibiotics and wound care. The 
records show that you are improving but still require basic care and physical and occupational therapy. You 
require short-term additional acute care hospital services that can be safely completed at the current facility 
until more appropriate for a lower level of care. You do not require services at the LTACH that are not already 
available at the current facility. There are no services at the LTACH that you require that are not already 
available and covered at the current facility. The LTACH services are not reasonable or 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve LTACH services. You say that LTACH admission is medically necessary. 
The Plan denied your request. The Plan says the enrollee's needs are being met in the current acute setting and 
the LTACH would offer no additional services. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found that the enrollee appears to be more stable and improving and should only require 
short-term additional acute care hospital services that can be safely completed at the current facility until more 
appropriate for a lower level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance mileage provided on May 17, 2021. 
 
You asked the Plan to pay for ambulance mileage. You say that the Plan made errors in this denial and you 
would like to have this claim paid correctly. The Plan denied your request. The Plan says that the denial of 
payment for this service is correct. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance providers may bill mileage rounded 
up to the nearest tenth of a mile for trips totaling up to 100 covered miles.  
 
We looked at the file and Medicare rules. The Plan chose to cover this ambulance transportation but did not 
pay for the ambulance mileage billed on this claim. You reported ambulance mileage code A0425 with 7.3 units, 
reflecting 7.3 covered loaded miles. The record shows that the loaded mileage of this trip was 7.3 miles. 
Therefore, you have billed mileage code A0425 in accordance with Medicare rules, and the Plan's decision to 
deny payment for this charge is baseless. Based on this information, we decided that Medicare rules for 
coverage of ambulance mileage have been met. Therefore, we decided that the Plan has to pay for ambulance 
mileage provided on May 17, 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.