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

 
We decided that the Plan does not have to pay for the surgical laparoscopic services coded 49652 and the 
surgical techniques requiring use of robotic surgical system coded S2900 provided on October 1, 2021. 
 
You asked the Plan to pay for the surgical laparoscopic services and the surgical techniques requiring use of 
robotic surgical system. You say that you disagree with the Plan's denial. The Plan denied your request. The 
Plan says the services billed are 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 CPT code.  
We find that CPT code 49652 is not supported in the medical record. Specifically, multiple hernias repaired 
during the same operative session through the same laparoscopic trocar sites, or through the same open 
laparotomy incision; and repaired with a single prosthetic sheet of mesh, when used, are considered inherently 
inclusive and cannot be reported separately. Additionally, multiple hernia defects of the abdominal wall, in 
proximity, count as a single hernia. Therefore, requested CPT code 49652 is denied as inclusive to CPT code 
49654. 
 
We find that procedure code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. 
 
Based on this information, we decided that Medicare rules for coverage of the surgical laparoscopic services 
and the surgical techniques requiring use of robotic surgical system have not been met. Therefore, we decided 
that the Plan does not have to pay for the surgical laparoscopic services coded 49652 and the surgical 
techniques requiring use of robotic surgical system coded S2900 provided on October 1, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cardiovascular panel (81185, 81286, 81400, 81413, 
81414, 81442 and 81479) billed for date of service June 5, 2021. You asked the Plan to pay for the cardiovascular panel. You say that these services are supported in the 
medical records. The Plan denied your request. The Plan says the provider's office indicated that they had not 
seen the enrollee for some time before this testing was provided. 
 
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. The rules also say that while a physician order for diagnostic tests does not 
necessarily need to be signed, the physician must clearly document intent for the test to be performed. Tests 
which are not clearly ordered by the physician who is treating the beneficiary are considered not reasonable and 
necessary. 
 
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 cardiovascular panel have been 
met. Specifically, the signature on the order form is not legible, and the information in the progress note does 
not support the intent for this testing to be performed. In addition, the records indicate that the test performed 
was a cardiovascular panel, but the test requisition form, although with an illegible signature, is clearly for a 
diabetes and obesity genetic test. Therefore, we decided that the Plan does not have to pay for the 
cardiovascular panel (81185, 81286, 81400, 81413, 81414, 81442 and 81479) billed for date of service June 5, 
2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an inpatient stay provided from March 16, 
2022, to March 19, 2022. 
 
You asked the Plan to waive the copayment for an inpatient stay. You say that the first day you were admitted, 
you were only in the room for an hour or so. Therefore, you feel you should not have to pay the copayment for 
that day. The Plan denied your request. The Plan says the copayment that was applied was 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 $290 
copayment per day, for days 1 to 6 for inpatient hospital care.  
 
You have been asked to pay a $870 copayment for an inpatient stay ($290 x 3 days = $870). An inpatient stay 
falls within the Inpatient Hospital Care 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 inpatient stay provided from March 16, 2022, to March 19, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device. 
 
You asked the Plan to pre-approve a MyoPro Motion G Orthotic device. You say that the requested MyoPro 
Motion G Orthotic device is medically necessary. The Plan denied your request. The Plan says the requested 
MyoPro Motion G Orthotic device 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 MyoPro Motion G Orthotic device. 
Our reviewer says that the requested MyoPro Motion G Orthotic device is not medically necessary. Our 
physician reviewer found based on the medical records provided and current clinical guidelines there is no 
documentation that the MyoPro Motion G Orthotic device at issue in this case meets Medicare criteria for 
medically reasonable and necessary. Current clinical guidelines designate robotic therapy to be of "uncertain 
utility compared with dose-matched conventional upper limb exercise therapies" with unproven benefit in the 
home environment. Although records from the device manufacturer/vendor argue medical necessity of the 
requested device, no records from the enrollee's actual treating provider clarify why the requested device is the 
most appropriate treatment for the enrollee's condition.  
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 MyoPro Motion G Orthotic device have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a MyoPro Motion G Orthotic device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the FoundationOne testing provided on February 22, 2022. 
 You asked the Plan to pay for the testing services. You say that the testing was necessary for the management 
of the enrollee's advanced cancer. The Plan denied your request. The Plan says the unique test identifier is 
missing. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate code. 
 
We looked at the file and the rules. The claim information does not show that the service was billed as 
required. Based on this information, we decided that Medicare rules for coverage of the testing services have 
not been met. Therefore, we decided that the Plan does not have to pay for the FoundationOne testing provided 
on February 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial observation care (99220) billed on November 25, 
2021. 
 
You asked the Plan to pay for initial observation care (99220). The Plan denied your request. The Plan says the 
medical records submitted do not support medical decision making of high complexity; therefore, procedure 
code 99220 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. 
 
 
  In this case, the CPT Code Manual definition of code 99220 is initial observation care, per day, for the 
evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A 
comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination 
of care with other physicians, other qualified health care professionals, or agencies are provided consistent with 
the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring 
admission to outpatient hospital "observation status" are of high severity. Typically, 70 minutes are spent at the 
bedside and on the patient's hospital floor or unit. 
 
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 initial observation care (99220). Our reviewer says that the 
medical documentation does not support the use of procedure code 99220. Our reviewer found that the medical 
decision making does not reach appropriate levels of high/comprehensive. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of initial observation care (99220) have not been met. Therefore, we decided that 
the Plan does not have to pay for initial observation care (99220) billed on November 25, 2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a CT scan of the abdomen and pelvis. 
 
You asked the Plan to pre-approve a CT scan of the abdomen and pelvis. You say that a CT scan of the 
abdomen and pelvis is medically necessary. The Plan denied your request. The Plan says that a CT of the 
abdomen and pelvis does not meet the Medicare coverage criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
medically necessary.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a CT scan of the abdomen and pelvis. 
Our reviewer says that a CT scan of the abdomen and pelvis is medically necessary. Our physician reviewer 
found that the enrollee has had extensive workup including upper endoscopy, colonoscopy, abdomen and 
pelvis ultrasound and some GI symptoms without an explanation for her weight loss. Due to the 10% weight 
loss and negative extensive work up a CT of the abdomen and pelvis is the last imaging step in a thorough 
workup and should be approved. 
 
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 CT scan of the abdomen and pelvis have been met. Therefore, we decided that 
the Plan has to pre-approve a CT scan of the abdomen and pelvis.  
 
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: 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 you were able to walk before your surgery but now 
you are not able to. You need acute intensive therapy to recover. The Plan denied your request. The Plan says 
you do not meet criteria for IRF care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee presented to the hospital on 9/5/2022 with back and leg pain and underwent spinal surgery. She was fitted with a thoracic-lumbar spinal brace. The records do not show acute 
rehabilitation or nursing needs. At the current functional level, the enroll does not need intensive therapies 
consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach in an 
IRF. It is also not likely that she will tolerate this intensity of treatment. 
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 20, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this code is separately payable. The Plan 
denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 20, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus xT Panel testing provided January 3, 2022. 
 
You asked the Plan to pay for the Tempus xT Panel testing. You say that this test was medically necessary. The 
Plan denied your request. The Plan says this test is not FDA-approved. Additionally, the Plan states that 
multiple genes were billed individually rather than under a single panel code. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare nationally covers FDA-approved NGS 
testing, when the test is FDA approved. 
 
We looked at the file and Medicare rules. Research shows that the Tempus xT tesing is not FDA approved. 
Based on this information, we decided that Medicare rules for coverage of the Tempus xT Panel testing have 
not been met. Based on this information, we decided that Medicare rules for coverage of the Tempus xT Panel 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the Tempus xT Panel 
testing provided January 3, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service April 22, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this code is separately payable. The Plan 
denied your request. The Plan says procedure code 99100 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 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service April 22, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on May 6, 2022, by an out-of-network 
(OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 services at issue in this appeal. The Plan did not pre-approve the 
services at issue.  We found no exception that would require the Plan to pay for these services. Therefore, we decided that the 
Plan does not have to pay for the services provided on May 6, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 6, 2022, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81306, 81335, 81355, 0031U, 0032U and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary 
and are supported in the medical records. The Plan denied your request. The Plan says these services were not 
billed in accordance with Medicare rules. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on April 6, 2022, billed with codes 81225, 81227, 81230, 81231, 81232, 81306, 81335, 81355, 0031U, 0032U and 
0033U.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 72128 and 72129 billed for date of service 
March 2, 2022.  
You asked the Plan to pay for procedure codes 72128 and 72129. The Plan denied your request. The Plan says 
the documentation does not indicate the appropriate use of codes es 72128-26-XU and 72129-26. The Plan says 
there is a different code to describe the combinations of contrast used in the CT scans. 
 
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 72128 is a column II code to column I code 72129; however, 72128 
was billed with a modifier.  
 
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 codes 72128 and 72129. Our reviewer says that 
the criteria for payment have not been met. Our reviewer found the documentation does not support the use of 
two separate procedure codes. Procedure code 72130 should be billed in the place of both 72129 and 72128. 
 
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 codes 72128 and 72129 have not been met. Therefore, we decided 
that the Plan does not have to pay for procedure codes 72128 and 72129 billed for date of service March 2, 
2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the segmental gradient pressure pneumatic appliance coded 
E0673 provided on January 3, 2022. 
 
You asked the Plan to pay for the segmental gradient pressure pneumatic appliance. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says the item was billed with an incorrect place 
of service. 
 
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 E0673 is not supported in the medical record. Specifically, the place of 
service for durable medical equipment claims is considered the location where a beneficiary will primarily use 
the durable medical equipment item. This durable medical equipment was billed with place of service 24 
(ambulatory surgical center). This place of service is not covered for durable medical equipment. This claim is 
not payable as billed. Based on this information, we decided that Medicare rules for coverage of the segmental 
gradient pressure pneumatic appliance have not been met. Therefore, we decided that the Plan does not have to 
pay for the segmental gradient pressure pneumatic appliance coded E0673 provided on January 3, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pair of glasses provided on April 26, 2022. 
 
You asked the Plan to pay for a pair of glasses. You say that the in-network provider was out of stock on 
several glasses, so you decided to go to the rendering provider. The Plan denied your request. The Plan says 
this provider is not a Medicare health plan provider.  
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services when the glasses (frame and lenses) or contact lenses are purchased 
from a network provider up to $300. 
 
We looked at the file and the Plan's rules. The record shows that the pair of glasses were purchased from a non-
participating provider with the Plan. Based on this information, we decided that the Plan's rules for coverage of 
a pair of glasses have not been met. Therefore, we decided that the Plan does not have to pay for a pair of 
glasses provided on April 26, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an electrocardiogram (EKG) during ambulance transport 
provided to the enrollee on April 4, 2022. 
 
You asked the Plan to pay for the EKG. You say that this should be paid for. The Plan denied your request. The 
Plan says this is not covered separately. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. An 
EKG is considered bundled into the main payment for ambulance services. 
 
In this case, the CPT Code Manual definition of code 93005 is "Electrocardiogram, routine ECG with at least 
12 leads; tracing only, without interpretation and report." 
 We find that CPT code 93005 is not supported in the medical record. Specifically, it is not appropriate to report 
an EKG done during ambulance transport separately. Based on this information, we decided that Medicare 
rules for coverage of the EKG have not been met. Therefore, we decided that the Plan does not have to pay for 
an electrocardiogram (EKG) during ambulance transport provided to the enrollee on April 4, 2022.