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

 
We decided that the Plan does not have to pay for procedure code 97530-GO-CO-KW billed for date of service 
September 1, 2021. 
 
You asked the Plan to pay for procedure code 97530-GO-CO-KW. You say that you have provided medical 
records to support payment of this code. The Plan denied your request. The Plan says The code billed is not 
appropriate for the services rendered. The provider should have used code G0158 to report these services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 97530-CO-CO-KX is Therapeutic activities, direct (one-
on-one) patient contact (use of dynamic activities to improve functional performance), each 15 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 procedure code 97530-GO-CO-KW. Our reviewer says that 
billing of this code is not supported by the medical records. Our reviewer found documentation describes 
therapy performed by a Certified Occupational Therapy Assistant (COTA) in the home. 
 In this case a more appropriate Healthcare Common Procedure Coding System (HCPCS) code should be 
reported for services performed in the home. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 97530-GO-CO-KW have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure code 97530-GO-CO-KW billed for date of service September 
1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide additional reimbursement for out of network services 
provided from April 19, 2021, to May 5, 2021. 
 
You asked the Plan to provide additional reimbursement for these services. You say that the Plan should 
reimburse you all of the money paid for these chiropractic services. The Plan denied your request. The Plan 
says the chiropractic services eligible for payment were covered. The Plan says they processed your 
reimbursement request against the Medicare Allowable rate for the services provided. The Medicare Allowable 
for each date of service is $40.79, and you were reimbursed a total of $326.32. The remaining amount of 
$253.68 is not covered by Medicare and there is no exception that would allow the Plan to reimburse the full 
out-of-pocket payment. 
 
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 chiropractic services are 
only covered from a network provider and the Plan only covers manual manipulation of the spine to correct 
subluxation.  
 
You received out of network chiropractic care. The Plan has reimbursed you for those services covered by 
Medicare. In addition, the Plan can only reimburse you the Medicare allowable amount for each service 
provided. Any chiropractic services other than manual manipulation of the spine would be your financial 
responsibility. Therefore, we decided that the Plan does not have to provide additional reimbursement for non-
covered out of network chiropractic services provided from April 19, 2021, to May 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for injection services provided to the enrollee on May 26, 2021 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 64415-59 LT (1 Unit) remains not supported. 
 
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 64415 is "Injection(s), anesthetic agent(s) and/or steroid; 
brachial plexus." 
 
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 the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found the anesthesia report is not clear if 
injection given was not to support general anesthesia. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for injection services provided to the enrollee on May 
26, 2021
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing (81479) provided on July 1, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says this claim was billed with an inappropriate 
place of service code. 
 
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the enrollee's face-to-face service was rendered in a laboratory setting. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing (81479) provided 
on July 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on July 27, 2021. 
 
You asked the Plan to pay for the Guardant360 testing. You say that POS 81 is the correct way to bill for this 
service. The Plan denied your request. The Plan says the POS code reported is not appropriate. 
 
The Plan must follow Medicare rules. Medicare rules say that the Place of Service (POS) code is generally used 
to reflect the actual setting where the beneficiary receives the face to-face service. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Guardant360 testing have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the member's face-to-face service was rendered in a laboratory 
setting. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on July 
27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the x-ray of the abdomen (74018) provided on  
November 7, 2021. You asked the Plan to pay for the x-ray of the abdomen. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 74018 
and 74019. 
 
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 74018 
is a column II code to column I code 74019. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the x-ray of the abdomen (74018) provided on  
November 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the subsequent nursing facility care (99309) provided on 
September 20, 2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the subsequent nursing facility care. You say that you would like reconsideration 
because the services provided were medically necessary. The Plan denied your request. The Plan says these 
services were not urgent, emergent of approved in advance. 
 
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 the subsequent nursing facility care (99309) 
provided on September 20, 2021 by an out-of-network (OON) provider.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the spinal cord stimulator trial. 
 
You asked the Plan to pre-approve the spinal cord stimulator trial. You say that you would like reconsideration 
because the requested trial is medically necessary. The Plan denied your request. The Plan says the member 
does not meet Medicare criteria for coverage. 
 
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 spinal cord stimulator trial. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the member has previously failed a spinal cord stimulator trial. His 
psychological evaluation was conducted on July 15, 2020. Having failed a prior trial, there is no reason to 
repeat it. 
 
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 spinal cord stimulator trial have not been met. Therefore, we decided that 
the Plan does not have to pre-approve the spinal cord stimulator trial.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for laparoscopic services provided to the enrollee on October 13, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that the denied procedure is considered inclusive to CPT 44202. 
 
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 49653 is "Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh 
insertion, when performed); incarcerated or strangulated." 
 
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 the services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found the operative report describes ventral 
hernia repair, with small intestine resection due to the ventral hernia.  Hernia repair codes report the repair of 
the hernia only.  Any excision or repair of strangulated organs or structures, if performed, would be reported 
with a separate code(s) in addition to the hernia repair. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for 
laparoscopic services provided to the enrollee on October 13, 2021. 
  
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on October 21, 
2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is unproven and 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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the documentation does not support that urine polymerase chain reaction (PCR) testing was medically 
reasonable and necessary for the enrollee in this case. The clinical utility of urine PCR testing remains to be 
established. Further study is required to determine the clinical importance of urine PCR testing.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on October 21, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Bevacizumab-awwb, Capecitabine and Oxaliplatin. 
 
You asked the Plan to pre-approve the Bevacizumab-awwb, Capecitabine and Oxaliplatin. You say that you 
would like reconsideration because the requested drugs are medically necessary. The Plan denied your request. 
The Plan says the documentation does not show any evidence that these drugs have helped prevent progression 
or maintain cancer in a stage. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the Bevacizumab-awwb, Capecitabine 
and Oxaliplatin. Our reviewer says that the documentation does not support that the requested drug regimen is 
medically necessary for this member. The documentation also does not support that this regimen is safe and 
effective for the member. Our physician reviewer found the record shows that the member's condition is 
progressing on this regimen and their therapy should be changed. 
 
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 Bevacizumab-awwb, Capecitabine and Oxaliplatin have not been met. 
Therefore, we decided that the Plan does not have to pre-approve the Bevacizumab-awwb, Capecitabine and 
Oxaliplatin.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 6, 2021, 
to April 7, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says inpatient admission was not medically necessary. 
 
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 does not support that the criteria for inpatient payment are met in this case. Our 
physician reviewer found the patient is a female with end stage renal disease who presented to the emergency 
room for right foot infection, missing her outpatient hemodialysis sessions the day prior. She was treated with 
IV antibiotics for cellulitis and had hemodialysis prior to admission without complication. She did not have 
signs of severe systemic infection or lack of response of outpatient antibiotics to justify inpatient care and 
dialysis could be completed at a lower level of care. The documentation did not suggest the patient required 
hospital services that would likely cross 2 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 not been met. Therefore, we decided that the 
Plan does not have to pay for the acute inpatient hospital care provided from April 6, 2021, to April 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve trial of an implanted spinal cord stimulator (SCS). 
 
You asked the Plan to pre-approve the SCS trial. You say that it is felt this should be approved. The Plan 
denied your request. The Plan says the enrollee has not been compliant with treatment, so it cannot be said to 
have failed. In addition, he has not been approved psychologically for the procedure. 
 
The Plan follows Medicare rules. Medicare rules say that SCS may be covered for enrollees with chronic pain 
as a late, if not last resort, when the other criteria listed in the Medicare rules section 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 the SCS trial. Our reviewer says that 
the requested SCS trial is not considered reasonable and necessary in this case. Our physician reviewer found 
the enrollee has chronic low back pain after a lumbar laminectomy surgery. He has recently refused to be 
examined and reports use of moonshine. The patient has not been compliant with treatments in the past, have 
had inconsistent urine drug testing results, and the psychological screening and evaluation found concerning 
issuing with past noncompliance and adjustment difficulties. The patient is not a suitable candidate for a 
SCS. The request 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 the SCS trial have not been met. Therefore, we decided that the Plan does not 
have to pre-approve trial of an implanted spinal cord stimulator (SCS).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to waive the coinsurance for an automatic external defibrillator (AED) 
vest provided from August 9, 2021, to September 9, 2021. 
 
You asked the Plan to waive the coinsurance for the AED vest. You say that the provider informed you that the 
vest would be fully covered. The Plan denied your request. The Plan says the correct coinsurance was applied. 
 
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 20% 
coinsurance for durable medical equipment (DME), including AED vests. 
 
 
 
 Item Allowed Amount 20% Coinsurance 
LifeVest  August 9, 2021 $2,800 $560 
LifeVest  September 9, 2021 $2,800 $560 
Total:  $1,120 
 
You have been asked to pay $1,120, which is 20% of the allowed amount for the AED vest. The AED vest falls 
within the Durable Medical Equipment (DME) and Related 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 coinsurance for an automatic external defibrillator (AED) vest provided from 
August 9, 2021, to September 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on  
November 6, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the provider did not bill as required by Medicare coding regulations. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70480 
is a column II code to column I code 70450. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for imaging services provided to the enrollee on November 6, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasound services provided to the enrollee on November 4, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says this service should not unbundled. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 76705 
is a column II code to column I code 93976. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for ultrasound services provided to the enrollee on November 4, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pathology consultation (88334) provided on December 
18, 2020. 
 
You asked the Plan to pay for the pathology consultation. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 88334 
and 88331. 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 88334 
is a column II code to column I code 88331. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for the pathology consultation (88334) provided on December 18, 
2020.