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

 
We decided that the Plan does not have to pay for the moderate sedation services coded as 99152 provided on 
October 20, 2021. 
 
You asked the Plan to pay for the moderate sedation services. You say that you would like this claim 
reprocessed based on the medical records. The Plan denied your request. The Plan says the documentation does 
not support payment for the code 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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 We find that CPT code 99152 is not supported in the medical record. Specifically, the medical documentation 
that has been submitted does not support the presence of an independent trained observer. Based on this 
information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. 
Therefore, we decided that the Plan does not have to pay for the moderate sedation services coded as 99152 
provided on October 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a tissue exam by a pathologist provided on March 9, 2022. 
 
You asked the Plan to pay for the tissue exam by a pathologist. You say that the service in dispute was denied 
in error, and you included clinical documentation to support payment of the code billed. The Plan denied your 
request. The Plan says procedure code 88305 has a PC/TC indicator of 1 and must be submitted with a modifier 
of 26. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. Medicare rules also say that an independent 
laboratory may not bill for the TC of a physician pathology service furnished in an outpatient hospital setting.  
 
We found that the pathology services which were billed were provided in an outpatient hospital setting. 
Independent laboratories may not bill for the TC of a physician pathology service furnished in an outpatient 
hospital setting. Based on this information, we decided that Medicare rules for coverage of the tissue exam by a 
pathologist have not been met. Therefore, we decided that the Plan does not have to pay for a tissue exam by a 
pathologist provided on March 9, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 29, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was billed 
incorrectly. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted. 
 
We looked at the file and Medicare rules. In this case, the claim was billed without the appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on April 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9328 billed for dates of service October 27, 
2021, to November 5, 2021. 
 
You asked the Plan to pay for procedure code S9328. You say that S9328 is billed for each 24-hour period the 
enrollee is provided with implanted pump pain management infusion. You say that S9328 is payable, and the 
claims should be reprocessed for payment. The Plan denied your request. The Plan says the billed code is 
invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
  We find that procedure code S9328 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9328 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S9328 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9328 billed for dates of service October 27, 2021, to November 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for perfusion pump services provided on March 29, 2022. 
 
You asked the Plan to pay for the services provided. You say that the services were provided in an in-network 
facility. The Plan denied your request. The Plan says the services are included in the payment made to the 
facility. 
 
The Plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other 
than the facility for services furnished to a beneficiary. 
 
We looked at the file and the rules. We find that the facility must furnish all necessary covered services to the 
beneficiary either directly or under arrangements made with outside providers. This service was provided via 
arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. 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 
perfusion pump services provided on March 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 0537T billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 0537T. You say that there are no bundling issues for this code 
according to the provider's billing and coding tool. The Plan denied your request. The Plan says procedure code 
0537T is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 0537T has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 0537T is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 0537T have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 0537T billed for date of service May 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve spinal surgery. 
 
You asked the Plan to pre-approve the surgery. You say that this is medically necessary. The Plan denied your 
request. The Plan says the physical exam was normal, and it is not clear why further surgery is planned. 
 
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 the surgery. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that there is no correlation between imaging and physical exam, showing any radiculopathy and nerve 
root compression on imaging. There is no instability on imaging. 
 
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 surgery have not been met. Therefore, we decided that the Plan does not 
have to pre-approve spinal surgery.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for membership fees for a public therapy pool. 
 
You asked the Plan to pay for membership fees for a public therapy pool. You say that the services of this 
therapy pool are medically necessary. The Plan denied your request. The Plan says this service is not covered 
because it is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that therapy services may be furnished appropriately 
in a community pool by a clinician in a physical therapist or occupational therapist private practice, physician 
office, outpatient hospital, or outpatient skilled nursing facility. When this is the case the practice/office or 
provider shall rent or lease the pool, or a specific portion of the pool. The use of that part of the pool during 
specified times shall be restricted to the patients of that practice or provider. 
 
We looked at the file and Medicare rules. In this case, you are requesting coverage for your membership fees 
for a public therapy pool. However, there is no documentation that you are currently under the care of a 
physical or occupational therapist. Furthermore, there is no documentation that the community pool is being 
leased by a therapist who is responsible for your rehabilitation care as required by Medicare rules. Based on 
this information, we decided that Medicare rules for coverage of membership fees for a public therapy pool have not been met. Therefore, we decided that the Plan does not have to pay for membership fees for a public 
therapy pool.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve allograft, morselized, or placement of osteopromotive 
material (20930). 
 
You asked the Plan to pre-approve allograft, morselized, or placement of osteopromotive material. You say that 
the requested service is medically necessary. The Plan denied your request. The Plan says the service at issue 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 allograft, morselized, or placement of 
osteopromotive material. Our reviewer says that the requested items/services are not considered medically 
reasonable and necessary in this case. Our physician reviewer found the efficacy of this procedure is not 
proven. 
 
   
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of allograft, morselized, or placement of osteopromotive material have not been 
met. Therefore, we decided that the Plan does not have to pre-approve allograft, morselized, or placement of 
osteopromotive material (20930).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode 
array, epidural (63650) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the patient has had previous procedures with 
minimal relief. The Plan denied your request. The Plan says that the enrollee does not meet requirements for 
these services. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. The patient does not 
have an evidence based indication for a spinal cord stimulator trial. Our physician reviewer found that the 
enrollee's condition does not meet criteria for coverage of these 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve percutaneous implantation of neurostimulator electrode array, epidural (63650) for the 
enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the lumbar epidural steroid injection (62323). 
 
You asked the Plan to pre-approve the injection. You say that you feel that the enrollee would benefit from this 
procedure and you are appealing the denial. The Plan denied your request. The Plan says the clinical 
information provided does not support that the enrollee meets the 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 the injection. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found in this case, no notes were provided stating the enrollee had failed a 4-week conservative 
therapy trial or could not tolerate one.  No rehabilitation program, home exercise program, or functional 
restoration program was planned following the epidural injection. The review has determined that the records 
do not show that the enrollee has met the medically necessary criteria for the requested service. 
 
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 injection have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the lumbar epidural steroid injection (62323).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the COVID-19 at-home test purchased on January 22, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the item at 
issue is an OTC item. Coverage for COVID-19 at-home tests must be submitted to Original Medicare. 
Therefore, we decided that the Plan does not have to pay for the COVID-19 at-home test purchased on January 
22, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for CT scan on December 17, 2021. 
 
You asked the Plan to waive the copayment for CT scan. You say that you should not owe because the CT of 
the chest should be covered as your yearly mammogram. The Plan denied your request. The Plan says the cost 
sharing you are being charged is correct. 
 
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 (not including x-rays). Advanced imaging (Services such as: CT, 
CTA, MRI, MRA, nuclear stress test, PET scans, SPECT.). The provider billed in the amount of $445 and the 
allowed amount is $168.51. This is less than the copayment amount. Therefore, results in the total cost sharing 
amount of $168.51. 
 
 
 
 You have been asked to pay a $168.51 copayment, which is less than the copayment for CT scan. 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 CT scan on December 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the critical care services provided from January 14, 2022, to 
January 16, 2022. 
 
You asked the Plan to pay for the services provided. You say that the codes are payable as billed. The Plan 
denied your request. The Plan says the billed services cannot be verified. 
 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 99291 is not supported in the medical record. Specifically, the records provided do not 
document the total time that the critical care services were furnished. Based on this information, we decided 
that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the 
Plan does not have to pay for the critical care services provided from January 14, 2022, to January 16, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs IRF care. The Plan denied your 
request. The Plan says IRF care is not medically necessary. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
rehabilitation program. There is not a reasonable expectation that you 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 22845 billed for date of service December 8, 
2021. 
  You asked the Plan to pay for procedure code 22845. You say that the hardware is separate from the cage and 
is not integral to the cage. You say that the service is separately paid and should be submitted for payment. The 
Plan denied your request. The Plan says payment for code 22845 is bundled into payment for code 22853. 
 
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 22845 
is a column II code to column I code 22853. 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 22845 billed for date of service December 8, 
2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Dupixent injection. 
 
You asked the Plan to pre-approve Dupixent. You say that the enrollee has been doing well on this drug. The 
Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-
administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the 
requested drug is not covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Dupixent injection.  
 Benefits for Dupixent may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc Syringe. 
 
You asked the Plan to pre-approve Synvisc. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the requested drug does not meet step therapy criteria. 
 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Synvisc. Our reviewer says that the 
documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer 
found the enrollee has a diagnosis of bilateral primary osteoarthritis of the knees. The documentation does not 
support that the enrollee has tried and failed Gel-One (Hyaluronate Sodium) and Euflexxa (Hyaluronate 
Sodium). The documentation does not support that Gel-One or Euflexxa would likely be less effective, and/or 
would likely have adverse effects for the enrollee in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Synvisc have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Synvisc Syringe.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on February 7, 2022. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
incorrectly. 
 The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. The services in this case were not billed with an appropriate DEX Z-
Code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. 
Therefore, we decided that the Plan does not have to pay for the genetic testing provided on February 7, 2022.