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

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service September 
14, 2022. 
 
You asked the Plan to pay for procedure code 76641. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says the number of units billed exceeds the 
maximum allowed.  
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 76641 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 
procedure code 76641 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 76641 billed for date of service September 14, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for procedure codes 82435, 84132, and 84295 billed for date of service 
November 11, 2021. 
 
You asked the Plan to pay for the billed services. The Plan denied your request. The Plan says that no modifiers 
are allowed with the code pairs. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The file shows the Plan denied payment as there is a modifier indicator of 0 between code 80051 and the 
denied codes 82435, 84132, and 84295. We find that codes 82435, 84132 and 84295 do not have a modifier 
indicator of 0 when billed with code 80051. The Plan has not made reasonable and diligent efforts to gather and 
forward to us information regarding their decision to deny your request.  Therefore, we decided that the Plan 
has to pay for procedure codes 82435, 84132, and 84295 billed for date of service November 11, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on June 30, 2022. 
 
You asked the Plan to pay for the office visit. You say that you were not informed in advance that the first 
appointment with a chiropractor is not covered by your insurance. The Plan denied your request. The Plan says 
the provider is a chiropractor and the coverage by this type of provider extends to the treatment by means of 
manual manipulation of the spine. No other diagnostic, office visit or therapeutic service furnished by a 
chiropractor is covered. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on June 30, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an electric patient lift (E0630). 
 
You asked the Plan to pre-approve the lift. You say that this is medically necessary. The Plan denied your 
request. The Plan says the lift provided by the plan is difficult to use to transfer. 
 
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 lift. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that the plan has supplied a hydraulic lift and has declined to supply an electric lift. The hydraulic lift is 
standard issue for a person who would otherwise be bed confined. The record from the provider does not offer 
information as to why the standard issue is not sufficient to meet the enrollee's needs. 
 
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 lift have not been met. Therefore, we decided that the Plan does not have to 
pre-approve an electric patient lift (E0630).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the GuardantReveal test provided to the enrollee on June 13, 
2022. 
 
You asked the Plan to pay for to pay for. You say that this was medically necessary. The Plan denied your 
request. The Plan says there is insufficient data to recommend post-surgery ctDNA testing to estimate risk of 
recurrence or determine adjuvant therapy. 
 
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 to pay for. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that per ClinicalTrials.gov, a pilot study investigating the feasibility to perform prospective circulating 
tumor DNA (ctDNA) profiling in patients with colorectal cancer is being conducted as of 10/1/20 with completion date of 12/2024. There is insufficient data to recommend post-surgery ctDNA to estimate risk of 
recurrence or determine adjuvant therapy. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of to pay for have not been met. Therefore, we decided that the Plan does not have 
to pay for the GuardantReveal test provided to the enrollee on June 13, 2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a chest x-ray provided on February 13, 2022. 
 
You asked the Plan to pay for the x-ray. The Plan denied your request. The Plan says that this claim is a 
duplicate of a previously paid claim and was correctly denied. 
 
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be 
exact duplicates of another claim or claim line are denied. However, such denials may be appealed. 
 
We looked at the file and Medicare rules. We find that the file does not include sufficient evidence to support 
the Plans argument that the claim at issue is a duplicate. Specifically, there is no evidence of another claim 
submission for the same procedure or of prior payment on this service. Based on this information, we decided 
that Medicare rules for coverage of the x-ray have been met. Therefore, we decided that the Plan has to pay for 
a chest x-ray provided on February 13, 2022.  
 
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 20, 
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 there was an incomplete/invalid physician order. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. Medicare rules say that a physician order must be present for labs to be covered. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of the services have been met. The 
documentation submitted did not include a valid physician order. There were no credentials or National 
Provider Identifier (NPI) on the submitted order.. Therefore, we decided that the Plan does not have to pay for 
laboratory services provided to the enrollee on October 20, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 12 additional physical therapy visits. 
 
You asked the Plan to pre-approve physical therapy. You say that the enrollee would like reconsideration 
because the services are medically necessary. The Plan denied your request. The Plan says 12 additional 
physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
   
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 physical therapy. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found that the training is primarily focused on strength. Strength training is 
primarily repetitive exercise and does not require cont'd unique input from a skilled therapist. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of physical therapy have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 12 additional physical therapy visits.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive urine drug testing (UDT) for 22 or more drug 
classes (procedure code G0483) provided to the enrollee on December 7, 2021. 
 
You asked the Plan to pay for the testing. You say that this should be paid for. The Plan denied your request. 
The Plan says the medical records do not show screening test results which are positive or inconsistent with 
prescription medications, dosing schedules, or history and expected results. 
 
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 testing. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the diagnosis is medication management of long term (current) drug therapy. The medical record 
sent by the provider shows screening test results which are positive or inconsistent with prescription 
medications, or history and expected results. Definitive confirmation testing was medically necessary for only 
1 drug class: Oxycodone. 
 
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 testing have not been met. Therefore, we decided that the Plan does not have 
to pay for definitive urine drug testing (UDT) for 22 or more drug classes (procedure code G0483) provided to 
the enrollee on December 7, 2021.
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 services are medically necessary to help you 
rebuild your strength. The Plan denied your request. The Plan says you don't meet the requirements based on 
your current medical condition. 
 
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 your medical problems are stable and no rehab nursing needs were identified. While 
you will benefit from physical and occupational therapy, your rehab needs can be safely met in an alternate 
setting. 
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a limited bilateral non-invasive physiologic study (procedure 
code 93922) provided to the enrollee on March 14, 2022.  
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 93922-59 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 93922 is "Limited bilateral noninvasive physiologic 
studies of upper or lower extremity arteries, (eg, for lower extremity: ankle/brachial indices at distal posterior 
tibial and anterior tibial/dorsalis pedis arteries plus bidirectional, Doppler waveform recording and analysis at 
1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus 
volume plethysmography at 1-2 levels, or ankle/brachial indices at distal posterior tibial and anterior 
tibial/dorsalis pedis arteries with, transcutaneous oxygen tension measurement at 1-2 levels)." 
 
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 that the procedure report does not 
include sufficient documentation to confirm a complete bilateral noninvasive physiologic to include per CPT 
code description "3 or more levels indices at distal posterior tibial and anterior tibial/dorsalis pedis arteries plus 
segmental blood pressure measurements with bidirectional doppler wave form recording and analysis, at 3 or 
more levels." In this case, CPT 93922 was reported with modifier -59 distinct procedural service, which cannot 
be verified, as the primary procedure cannot be confirmed as performed. 
 
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 a limited bilateral non-invasive physiologic study (procedure code 93922) provided to the 
enrollee on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for medical services provided on August 4, 2021. 
 
You asked the Plan to reimburse you for the requested medical services. You say that there is a breach of 
contract, and a refund needs to be issued. The Plan denied your request. The Plan says that the Plan needs to know whether you paid and need reimbursement or whether the Plan needs to pay your provider. Please send a 
receipt as explained in your Plan document. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of medical services provided by the 
requested provider have been met. The file is missing the required receipts for the Plan to determine who to 
reimburse, and also the medical documentation to determine if the medical services meet the emergency or 
urgently needed coverage criteria. Therefore, we decided that the Plan does not have to reimburse you for 
medical services provided on August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit (99202) provided on April 18, 2022. 
 
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says this service is not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for the office visit (99202) provided on April 18, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from April 27, 2022, to 
May 26, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that a timely notice of admission was 
submitted. The Plan denied your request. The Plan says the claim has not been billed with the correct 
admission date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment have not been met. Therefore, we decided that the 
Plan does not have to pay for the home health services provided from April 27, 2022, to May 26, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable oxygen concentrator, rental (E1392). 
 You asked the Plan to pre-approve a portable oxygen concentrator. You say that the oxygen tanks provided are 
impossible for you to go any place you need as you cannot hold your walker and roll the oxygen at the same 
time and the smaller tanks with a backpack is too heavy for your to carry. The Plan denied your request. The 
Plan says there is no indication the member's current oxygen equipment is not meeting their medical needs or 
activities of daily living in or around the home. 
 
The Plan must follow Medicare rules. The rules say that to qualify for portable oxygen, the patient must meet 
the criteria for home oxygen. The documentation must show that the patient is mobile in the home and would 
benefit from the use of portable oxygen in the home. Portable oxygen is not covered for patients who qualify 
for oxygen solely based on blood gas studies obtained during sleep.   
 
To qualify for home oxygen, the patient must meet one of the following blood gas levels: 
 
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep;  
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
For patients with arterial PO2 at or above 60 mm Hg or arterial O2 saturation at or above 90% on room air, 
there is a rebuttable presumption of non-coverage. 
 
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 portable oxygen concentrator. Our 
reviewer says that a portable oxygen concentrator is not medically necessary. Our physician reviewer found 
this enrollee has mitral stenosis and congestive heart failure and is on continuous oxygen. The enrollee has 
been provided with portable B tanks and a backpack. The enrollee states these are too heavy to carry. However, 
a portable concentrator weighs about the same as the B tanks. Also, there is no testing to confirm that SpO2 can 
be maintained at or above 91% during activity using an oxygen conserving device with flow rate 1 to 4 L/min, 
as required by Medicare. A portable oxygen concentrator 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 a portable oxygen concentrator have not been met. Therefore, we decided that 
the Plan does not have to pre-approve a portable oxygen concentrator, rental (E1392).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a third opinion with an in-network neurosurgeon. 
 
You asked the Plan to pre-approve a third opinion. You say that you need a third opinion regarding your back 
pain. You say that your regular neurosurgeon decided to abandon your care. You also say that you need a new 
provider for an updated evaluation of the progression of your condition. The Plan denied your request. The 
Plan says a third opinion 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 third opinion. Our reviewer says that 
the request for a third opinion is not considered medically reasonable and necessary in this case. Our physician 
reviewer found the provided documentation indicates that you have already had two surgical opinions from 
qualified provider. Therefore, the reviewer found that a third opinion 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 a third opinion have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a third opinion with an in-network neurosurgeon.