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

 
We decided that the Plan does not have to pay for the WATS 3D biopsy testing provided on May 17, 2021. 
 
You asked the Plan to pay for the WATS 3D biopsy testing. You say that this is a medically indicated test for 
the enrollee's condition. The Plan denied your request. The Plan says there is insufficient literature support for 
this testing. 
 
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 WATS 3D biopsy testing. Our reviewer 
says that the requested services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the record indicates that the has long segment Barretts esophagus without dysplasia in the setting of gastroesophageal reflux disease. The literature does not support the safety and efficacy of the 
requested service, as defined by Medicare rules, for the enrollee's clinical condition. The American Society of 
Gastrointestinal Endoscopy has given the requested service a conditional recommendation for the noted use 
with low quality of evidence, insufficient to establish the safety and efficacy of the requested service, as 
defined by Medicare rules, 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.  
 
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 WATS 3D biopsy testing have not been met. Therefore, we decided that the 
Plan does not have to pay for the WATS 3D biopsy testing provided on May 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physicians services (99309) provided August 27, 2021. 
 
You asked the Plan to pay for the physicians services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 99309 is Subsequent nursing facility care, per day for the 
evaluation and management of a patient, which requires at least 2 of these 3 key components: a detailed 
interval history; a detailed examination; medical decision making of moderate complexity. 
 
We find that CPT code 99309 is not supported in the medical record. Specifically, the records show medical 
decision making of a low complexity. Based on this information, we decided that Medicare rules for coverage 
of the physicians services have not been met. Therefore, we decided that the Plan does not have to pay for 
physicians services (99309) provided August 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator (E0466). 
 
You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied 
your request. The Plan says the home ventilator is not medically reasonable and necessary. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that 
the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the Life2000 
System is not medically necessary. This system is not a true ventilator, because it is not capable of providing 
full ventilatory support. It provides positive pressure oxygen, and is designed for use during activity.  There are 
no high quality controlled clinical trials demonstrating benefits of this device in the treatment of COPD. 
Furthermore, the enrollee does not meet criteria for a home ventilator.  Medicare does not cover a home ventilator when used as bipap. There is no arterial blood gas (ABG) study 
done when the enrollee is stable as an outpatient showing C02 retention. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a home ventilator (E0466).
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the 2-view left wrist x-ray provided on 
November 10, 2021, billed with code 73100. 
 You asked the Plan to pay for the wrist x-ray interpretation. You say that it is felt that this code should be paid. 
The Plan denied your request. The Plan says this was provided on the same date as Column 1 code 73110. 
These can only be paid on the same date when an NCCI modifier is used. 
 
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 73100 
is a column II code to column I code 73110. 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 interpretation of the 2-view left wrist x-ray provided on 
November 10, 2021, billed with code 73100.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy services. 
 
You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your 
request. The Plan says the services are not necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 
 
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 services. Our reviewer says that the 
requested services are not medically reasonable or necessary. Our physician reviewer found the documentation 
doesnt support that the enrollee requires additional skilled nursing services or skilled rehab services to provide 
treatment that is medically necessary. The member does not require additional skilled nursing or rehab services 
to effectively provide treatment, care, and/or services in order to improve the enrollees condition, perform a 
maintenance program to maintain the members condition and/or prevent deterioration. The enrollee has been 
medically stable without any recent exacerbations of chronic medical problems or hospitalizations. She has 
worked with physical therapy to establish a home exercise program. The requested home health services are 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve home health physical therapy services.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Feraheme. 
 
You asked the Plan to pre-approve Feraheme. You say that Feraheme is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet Step Therapy criteria for coverage of the Feraheme. 
 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Feraheme. Our reviewer says that 
Feraheme is not medically necessary at this time. Our physician reviewer found the requested medication is a 
new start. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step 
one alternative. The record does not indicate that the enrollee has a contraindication to or would have an 
adverse effect from the plan's preferred step one alternative. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Feraheme have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Feraheme.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary. The Plan denied 
your request. The Plan says the enrollee does not meet Medicare criteria for coverage of SNF care. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found the enrollee does not require skilled nursing or 
therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria 
for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services (90834) provided 
September 22, 2021. 
 You asked the Plan to pay for the outpatient mental health services. You say that the service was medically 
necessary. The Plan denied your request. The Plan says there is no record that an attempt was made to consult 
the primary treating physician. 
 
The Plan must follow Medicare rules. Medicare rules say that the CP or LCSW must document, in the patient's 
medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, 
if attempts to consult did not succeed, that date and manner of notification to the physician. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the outpatient mental health services have not been met. Specifically, the record does not include 
documentation of a consultation or an attempt to consult the enrollee's primary/attending physician as required 
by Medicare rules. Therefore, we decided that the Plan does not have to pay for outpatient mental health 
services (90834) provided September 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous intraoperative neurophysiology monitoring 
(G0453) provided on March 4, 2021. 
 You asked the Plan to pay for the continuous intraoperative neurophysiology monitoring. 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 code G0453 and 51785. 
 
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 G0453 
is a column II code to column I code 51785. 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 continuous intraoperative neurophysiology monitoring 
(G0453) provided on March 4, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic activities, direct (one-on-one) patient contact 
(use of dynamic activities to improve functional performance), each 15 minutes (CPT code 97530 GO CO KX) 
provided on August 19, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is 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. 
 
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 found the reviewed 
documentation indicates that medical records were required to submit Therapeutic activities; direct (one-on-
one) patient contact (use of dynamic activities to improve functional performance); each 15 minutes related to 
the billed service. In addition, the submitted medical records indicate this service was performed in place of 
service 12. There is a more appropriate Healthcare Common Procedure Coding System (HCPCS) code that should be used to report services provided to an occupational therapy patient in the home setting. Therefore, the 
service; the units and submitted modifiers cannot be verified. The submitted documentation contained 
occupational therapist note, and progress note. HCPCS/CPT code(s) 97530 GO KX (4 units); for billed date 
August 19, 2021. The review has determined that the service was not supported in the records provided. 
 
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 the therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to 
improve functional performance), each 15 minutes (CPT code 97530 GO CO KX) provided on August 19, 
2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for dental surgical pathology services received on  
November 12, 2021. 
 
You asked the Plan to pay for the services. You say that this was a removal and biopsy of a suspected lesion on 
the lower jaw, and should be covered. The Plan denied your request. The Plan says currently, Medicare will 
pay for dental services that are an integral part either of a covered procedure or for extractions done in 
preparation for radiation treatment for neoplastic diseases under Part B when performed by a physician. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pay for involve the care, treatment, filling, removal or replacement of 
your teeth or the structures directly supporting your teeth. These are dental services that are not covered or paid 
for by Medicare. Therefore, we decided that the Plan does not have to pay for dental surgical pathology 
services received on November 12, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing (G0483) provided on June 8, 2021. 
 
You asked the Plan to pay for the drug testing. You say that you would like reconsideration based on the 
records submitted. The Plan denied your request. The Plan says this claim was not submitted with the correct 
POS code. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the drug testing have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the drug testing (G0483) provided on June 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Guardant360 testing provided on July 20, 2021. 
 
You asked the Plan to pay for the testing services. You say that there has been a misinterpretation of the 
guidelines. The Plan denied your request. The Plan says the billed code 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 code. 
 
The claim lists a place of service as 81, an independent laboratory. We looked at the file and the rules. If an 
independent lab bills for services, the place where the sample was taken is reported as the place of service. The 
records provided do not show that the specimen at issue was obtained at the independent laboratory. Based on 
this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that 
the Plan does not have to pay for the Guardant360 testing provided on July 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on March 9, 
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 records do not support the services billed. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for laboratory services provided to the enrollee on March 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple repair of superficial wounds (CPT code 12013) 
provided on May 22, 2021. 
 
You asked the Plan to pay for the outpatient service. 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. In this case, we have confirmed that code 12013 
is a column II code to column I code 12002. 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 simple repair of superficial wounds (CPT code 12013) 
provided on May 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for initial hospital care (CPT code 99232) provided on October 
17, 2021. 
 
You asked the Plan to pay for initial hospital care. 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. 
 
Per the CMS Medical Unlikely Edits (MUE) table, the MUE value for CPT code 99232 is set at 1 per date of 
service. Review of claims history shows the exact same service (99232) was already billed for this patient and 
for same date of service by the same provider. Based on this information, we decided that Medicare rules for coverage of initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay 
for initial hospital care (CPT code 99232) provided on October 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the DME (CPT code(s): E0673 and E0675) provided on May 
4, 2021. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must be appropriate 
and needed for use inside the home. Medicare does not consider a SNF or a hospital to be a home.  
 Records show that the DME was used in a SNF or hospital. Therefore, we decided that the Plan does not have 
to pay for the DME (CPT code(s): E0673 and E0675) provided on May 4, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from August 20, 2021, through 
September 1, 2021. 
 
You asked the Plan to pay for SNF care. You say that the stay was medically necessary. The Plan denied your 
request. The Plan says the stay was not medically necessary based on SNF criteria.  
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found no required skilled nursing services are 
identified. No required skilled therapy services are identified in the case file for the dates at issue. It is not 
medically reasonable and necessary to provide these skilled nursing or skilled therapy services (or a 
combination of these services) on a "daily basis". 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from August 20, 2021, through September 1, 2021.