Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for inpatient hospital care provided from March 10, 2020, 
through March 17, 2020. 
 
You asked the Plan to pay for inpatient hospital care. You say that you submitted supporting documentation for 
reconsideration of DRG adjustment. The Plan denied your request. The Plan says they are upholding their decision to replace code N17.0 with N17.9 (Acute kidney failure, unspecified); therefore, this recommendation 
results in a change from DRG 492 to DRG 493. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
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 inpatient hospital care. Our physician 
reviewer found the patient presented following a syncopal event at home that was noted to be in the setting of 
recent change in blood pressure medications and new onset atrial fibrillation. The patient also reported only one 
functional kidney and baseline creatinine was documented to be 1.5 to 1.8. In this case, the urinalysis was not 
found for review; however, documentation indicated the UA was "not suggestive" and the Nephrology consult 
noted "Generally negative urine". Review of the laboratory data noted a urine sodium of 28 and a urine 
creatinine of 341. Based on serum chemistries available for review, the FeNa was calculated to be 0.2%. While 
the creatinine did increase to 3.63 following admission, the patient was placed on intravenous fluids, 
medications were held, and the creatinine improved to 1.03 by discharge. The review has determined that 
replacing code N17.0 with N17.9 (Acute kidney failure, unspecified) was not supported by the records 
provided for review.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for inpatient hospital care provided from March 10, 2020, through March 17, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code G0483) provided on May 
25, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered as billed. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. CPT code G0483-90 
remains not supported. The Plan of service on the CMS-1500 form line 24B must reflect the location of the 
patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11; therefore, the billed code cannot be verified. It is 
noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided 
that the Plan does not have to pay for the laboratory services (CPT code G0483) provided on May 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 81455) provided on 
October 8, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the services were necessary. The Plan 
denied your request. The Plan says the services are not covered. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the laboratory services have not been met. This genomic sequence 
analysis panel, CPT 81455 Targeted genomic sequence analysis panel, solid organ or hematolymphoid 
neoplasm, DNA analysis, and RNA analysis when performed, 51 or greater genes, is non-covered by Medicare. 
Genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in 
the clinical management of the patient and will be denied automatically as not medically necessary and 
screening testing. Therefore, we decided that the Plan does not have to pay for the laboratory services (CPT 
code 81455) provided on October 8, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy assistant (PTA) services provided on 
October 2, 2021. 
 
You asked the Plan to pay for the medical services. You say that these services were medically necessary. The 
Plan denied your request. The Plan says there is a more comprehensive code for these services than what was 
billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a PTA are subject to the criteria 
listed in the Medicare rules section.  
 
We looked at the file and Medicare rules. In this case, the NPP is billing for the services of the PTA, which is 
not allowed per the cited rules. Based on this information, we decided that Medicare rules for coverage of the 
medical services have not been met. Therefore, we decided that the Plan does not have to pay for the physical 
therapy assistant (PTA) services provided on October 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization surgery. 
 
You asked the Plan to pre-approve genicular artery embolization surgery. You say that this procedure is 
medically necessary. The Plan denied your request. The Plan says the requested procedure is considered 
experimental/investigational. 
 
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 genicular artery embolization surgery. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the record indicates that the enrollee has osteoarthritis of the knee. The 
available literature is insufficient to demonstrate the safety and efficacy, as defined by Medicare rules, of the 
requested service for the enrollee's clinical condition. The record provided does not establish the medical 
necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the 
coverage criteria are not satisfied. The requested service is not recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of genicular artery embolization surgery have not been met. Therefore, we decided 
that the Plan does not have to pre-approve genicular artery embolization surgery.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular pertussis 
vaccine (Tdap) (90715 and 90471) provided on November 1, 2021. 
 
You asked the Plan to pay for the Tdap vaccine. You say that you would like reconsideration because you had 
fallen and had cuts which appeared to be infected. The Plan denied your request. The Plan says this vaccination 
is not covered when billed with a non-covered diagnosis. 
 
The Plan follows Medicare rules. Medicare rules say that in the absence of injury or direct exposure to illness, 
Medicare does not pay for or provide the Tdap vaccine. The Plan follows the same rules. 
 
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 Tdap vaccine. Our reviewer says that in 
the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) is not covered. 
Our physician reviewer found the documentation did not support that this vaccine was directly related to the 
treatment of an injury or direct exposure to a disease or 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 the Tdap vaccine have not been met. 
Therefore, we decided that the Plan does not have to pay for the Tetanus, diphtheria toxoids and acellular 
pertussis vaccine (Tdap) (90715 and 90471) provided on November 1, 2021.  
 
Benefits for the Tdap vaccine 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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve proton beam therapy with image-guided radiation 
therapy (IGRT). 
 
You asked the Plan to pre-approve proton beam therapy with IGRT. You say that the requested services are a 
medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not 
been met because the requested services are experimental/investigational. 
 
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 proton beam therapy with IGRT. Our 
reviewer says that the requested services are not considered medically reasonable and necessary in this case. 
Our physician reviewer found that whether proton beam therapy affords a benefit over other standard 
approaches for prostate cancer is an area of investigation and remains controversial. The generally accepted 
standard of care for prostate cancer is to only offer proton beam therapy on clinical trials and to not routinely 
offer it to patients. It is not clear if the enrollee agreed to a study or is eligible. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of proton beam therapy with IGRT have not been met. Therefore, we decided that 
the Plan does not have to pre-approve proton beam therapy with image-guided radiation therapy (IGRT).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to provide coverage for a continuous glucose monitor. 
 
You asked the Plan to provide coverage for a continuous glucose monitor. You say that a continuous glucose 
monitor. The Plan denied your request. The Plan says based on the medical records provided, all the of the 
required criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 Based on the medical records provided, you do not meet all of these criteria. Therefore, we decided that the 
Plan does not have to provide coverage for a continuous glucose monitor.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (CPT code 81479) provided on December 
23, 2020. 
 
You asked the Plan to pay for the genetic testing. You say that the services were necessary. The Plan denied 
your request. The Plan says FoundationOne Liquid CDx does not have FDA approval/clearance for cervical 
cancer which is the enrollee's diagnosis. The Plan states it is also not clear from documentation that the enrollee 
has not had the same test prior as no oncology notes were submitted. 
 
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 genetic testing. Our physician reviewer 
found the provided documentation did not show whether the enrollee has already had this test before or not, 
and FoundationOne Liquid CDx does not have FDA approval/clearance for cervical cancer. Therefore, the 
enrollee does not meet requirements for Medicare coverage based on the provided documentation. 
 
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 genetic testing have not been met. Therefore, we decided that the Plan does 
not have to pay for the genetic testing (CPT code 81479) provided on December 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a high frequency chest wall oscillation system (E0483) 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a high frequency chest wall oscillation system. You say that the enrollee 
needs this item. The Plan denied your request. The Plan says there are in-network options available if this is 
medically necessary. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a high frequency chest wall oscillation system (E0483) to be provided by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home infusion therapy (CPT code S9501) provided from 
June 8, 2021, through June 13, 2021. 
 
You asked the Plan to pay for home infusion therapy. You say that the claim should be paid. The Plan denied 
your request. The Plan says the service is not covered 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. 
 
CPT code S9501, has a status code I Not valid for Medicare purposes. Medicare uses another code for 
reporting of and payment for these services. Based on this information, we decided that Medicare rules for 
coverage of home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay 
for home infusion therapy (CPT code S9501) provided from June 8, 2021, through June 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gingival irrigation (D4921) provided on October 12, 
2021. 
 
You asked the Plan to pay for the gingival irrigation. You say that you would like this claim to be paid. The 
Plan denied your request. The Plan says this service is not a covered expense under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
gingival irrigation (D4921) provided on October 12, 2021.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pay for adjacent tissue transfer or rearrangement (14301) and 3 units of 
additional transfer or rearrangement (14302x3) provided on October 5, 2021. 
 
You asked the Plan to pay for adjacent tissue transfer or rearrangement. You say that you have provided 
records to support the services billed. The Plan denied your request. The Plan says that rules for payment have 
not been met because the available records do not support the services 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 14301 is "Adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm" and of 
code 14302 "Adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof 
(List separately in addition to code for primary procedure)." 
 
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 adjacent tissue transfer or rearrangement. Our reviewer says 
that the services at issue meet criteria for reimbursement. Our reviewer found that the enrollee was underwent a 
lumpectomy with reconstruction with adjacent tissue rearrangement. The operative report describes the 
rearrangement of 150 square centimeters of tissue, not the raising of flaps. The elements of the coverage 
criteria for one unit of CPT code 14301 and three units of CPT code 14302 are satisfied. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of adjacent tissue transfer or rearrangement have been met. Therefore, we decided 
that the Plan has to pay for adjacent tissue transfer or rearrangement (14301) and 3 units of additional transfer 
or rearrangement (14302x3) provided on October 5, 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevator (E2300) for a power wheelchair. 
 
You asked the Plan to pre-approve the power seat elevator. You say that the seat elevator is medically 
necessary. The Plan denied your request. The Plan says this feature is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules state that a power seat elevation feature (E2300) and 
power standing feature (E2301) are non-covered because they are not primarily medical in nature. 
 
We looked at the file and Medicare rules. This feature is not eligible for coverage. Based on this information, 
we decided that Medicare rules for coverage of the power seat elevator have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a power seat elevator (E2300) for a power wheelchair.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office services provided on July 19, 2021, by an out-of-
network provider. 
 
You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan 
denied your request. The Plan says this provider is outside of the Plan's network of providers and there are no 
records of a prior authorization being obtained from the enrollee's primary care physician (PCP) to the health 
plan prior to the services being rendered on July 19, 2021. 
 
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 office services provided on July 19, 2021, by 
an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the brachytherapy source (CPT code C2616) provided on 
September 30, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says use of modifier(s) XU is not typical for procedure code C2616. 
 
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 the brachytherapy source (CPT code 
C2616) provided on September 30, 2021, have been met. The appellant did not submit documentation to verify if the services were supported. Therefore, we decided that the Plan does not have to pay for the brachytherapy 
source (CPT code C2616) provided on September 30, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance transport (A0428) and mileage (A0425), 
provided on December 18, 2021. 
 
You asked the Plan to pay for the ambulance service. You say that the service was medically necessary. The 
Plan denied your request. The Plan says the service was not medically necessary 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
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 ambulance service. Our reviewer says 
that the service was not medically necessary Our physician reviewer found the documentation did not support 
that other means of transport (such as stretcher van, wheelchair van, taxi, private car, or other type of vehicle) 
were contraindicated for this patient or that the patient needed the expertise, services and lifesaving and life-
sustaining equipment that only a fully-equipped ambulance can provide for safe transport. 
 
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 ambulance service have not been met. Therefore, we decided that the Plan does not have to pay for the ambulance transport (A0428) and mileage (A0425), provided on December 18, 
2021.