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

 
We decided that the Plan does not have to pay for FoundationOne Liquid CDx testing (0239U) billed for date 
of service April 15, 2021. 
 You asked the Plan to pay for FoundationOne Liquid CDx testing. You say that this test was necessary and is 
supported in the medical record. The Plan denied your request. The Plan says this test was billed with an 
incorrect date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that unless a specific exception is met, laboratory 
services should be billed for the date of service of the specimen collection.  
 
We looked at the file and Medicare rules. The records do not show that the specimen in this case was collected 
in an outpatient or inpatient hospital encounter. This means that none of the possible exceptions to the general 
rule have been met. The records show that the specimen in this case was collected on April 7, 2021, rather than 
the billed date of service of April 15, 2021. Based on this information, we decided that Medicare rules for 
coverage of FoundationOne Liquid CDx testing have not been met. Therefore, we decided that the Plan does 
not have to pay for FoundationOne Liquid CDx testing (0239U) billed for date of service April 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Synvisc injections. 
 
You asked the Plan to pre-approve Synvisc injections. You say that you want to avoid surgery. The Plan denied 
your request. The Plan says the requirements for coverage have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that viscosupplementation for intra-articular 
injections of the knee are considered reasonable and necessary when the records document trial and failure of at 
least 3 months of conservative therapy, including non-pharmacologic therapy (e.g., physical therapy, exercise, 
weight management, self-management programs, knee brace, cane). 
 
We looked at the file and Medicare rules. The records do not show you have failed three months of 
conservative therapy. Based on this information, we decided that Medicare rules for coverage of Synvisc 
injections have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc 
injections.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99053 billed for date of service September 5, 
2021. 
 
You asked the Plan to pay for procedure code 99053. You say that this claim was coded correctly and this code 
should be paid. The Plan denied your request. The Plan says procedure code 99053 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 99053 has a status indicator of B on the Physician Fee Schedule. This means that procedure code 99053 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99053 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99053 billed for date of service September 5, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for initial hospital care (99222) billed for date of service November 27, 
2021. 
 
You asked the Plan to pay for initial hospital care. You say that this service was billed appropriately and should 
be paid as it was provided by physicians from two different specialties on the date in question. The Plan denied 
your request. The Plan says that this service can only be billed once per day. 
 
The Plan must follow Medicare rules. Medicare rules say that initial hospital care is a per diem service which 
may be reported only once per day by the same physician or physicians of the same specialty from the same 
group practice. If a hospital inpatient sees two providers who are responsible for different aspects of the 
patients care and the claims are billed by providers with different specialties and different diagnoses, both 
visits are payable. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of initial hospital care have been met. Specifically, the enrollee was seen by two providers with 
different specialties and different primary taxonomy codes. One provider performed care relating to 
neurosurgery and the other provided critical care services. Both claims were billed with different diagnosis 
codes. This means both visits are payable. Therefore, we decided that the Plan has to pay for initial hospital 
care (99222) billed for date of service November 27, 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 pre-approve an external mobile cardiovascular telemetry with 
electrocardiographic recording (93228). 
 
You asked the Plan to pre-approve the evaluation and management service. You say that the enrollee has been 
having occasional pauses on telemetry monitoring. You say that the device is necessary to further assess the 
sinus pauses. The Plan denied your request. The Plan says the requested service is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that cardiac event detection is covered for 
symptomatic transient arrhythmias.  
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 evaluation and management service. 
Our reviewer says that the requested service is not considered medically reasonable and necessary in this case. 
Our physician reviewer found the provided documentation indicates that the enrollee had experienced transient 
short sinus pause without symptoms during cardiac rehabilitation telemonitoring. The reviewer found that there 
is no history of symptomatic transient arrhythmias. Therefore, the reviewer found that the requested service 
does not meet the criteria for coverage. 
 
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 evaluation and management service have not been met. Therefore, we 
decided that the Plan does not have to pre-approve an external mobile cardiovascular telemetry with 
electrocardiographic recording (93228).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing provided on October 6, 2021. 
 
You asked the Plan to pay for CxBladder testing. You say that this was medically necessary. The Plan denied 
your request. The Plan says this exceeds the standard of care. 
 
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 CxBladder testing. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the Cxbladder test is not the standard of care to assess bladder cancer and will be considered 
medically unnecessary as it goes beyond the standard of care without sufficient support provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of CxBladder testing have not been met. Therefore, we decided that the Plan does 
not have to pay for CxBladder testing provided on October 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 22600, 22854, 63081 and 63082 billed on 
January 10, 2022. 
 
You asked the Plan to pay for procedure codes 22600, 22854, 63081 and 63082. You say that the attached 
documentation shows these procedures. The Plan denied your request. The Plan says procedure code 63048 has 
been approved. The Plan also says procedure codes 22600, 22854, 63081 and 63082 are not supported by the 
medical records submitted. 
 
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 procedure codes 22600, 22854, 63081 and 63082. Our 
reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our 
reviewer found that the operative report does not include enough documentation to confirm an arthrodesis, 
insertion of intervertebral biomechanical device and vertebral corpectomy were performed. Therefore, these 
procedures cannot be verified. 
 
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 22600, 22854, 63081 and 63082 have not been met. Therefore, 
we decided that the Plan does not have to pay for procedure codes 22600, 22854, 63081 and 63082 billed on 
January 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab testing services provided on March 14, 2022. 
 
You asked the Plan to pay for the lab services. You say that the test was reasonable and necessary. The Plan 
denied your request. The Plan says the claim did not contain a DEX-Z code. 
 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. We find that the claim was not billed as required. Based on this 
information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we 
decided that the Plan does not have to pay for the lab testing services provided on March 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PrismRA lab testing services provided on May 4, 2022. 
 
You asked the Plan to pay for the lab services. You say that the test predicts non-response to tumor therapies. 
The Plan denied your request. The Plan says the test is not covered. 
 The Plan must follow Medicare rules. Medicare rules say that next generation sequencing is only covered under 
certain medical indications.  
 
We looked at the file and Medicare rules. The file shows that the lab testing at issue is not FDA approved. 
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 PrismRA lab testing services provided on May 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the wheelchair and sales tax you purchased on January 23, 
2022. 
 
You asked the Plan to pay for the wheelchair and sales tax. You say that you fell and broke your kneecap.  You 
said that you had a prescription for the wheelchair, and you could not find a place to purchase one on the date 
of the accident. The Plan denied your request. The Plan says this provider is not a Medicare-certified provider. 
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is 
not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at 
issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the 
wheelchair and sales tax you purchased on January 23, 2022.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for code 99217 billed for date of service March 17, 2022. 
 
You asked the Plan to pay for code 99217. You say that these services were billed correctly.  You said that you 
appropriately billed for the initial observation service (code 99220) for date of service March 16, 2022.  Then 
you appropriately billed code 99217 on the following date, as that was the date that the patient was discharged 
from observation. The Plan denied your request. The Plan says that the records do not support the frequency of 
services. 
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Specifically, the Plan has made no attempts to provide any evidence behind its 
assertion that the code isn't supported by the records.  The Plan has provided no evidence of other claims paid 
on this date of service. The Plan has failed to even address the arguments you laid out in your appeal letter. The 
Plan also also failed to cite to any rule upon which its denial was based. The burden is on the Plan to supply 
enough information to support its denial.  The Plan has failed to do so in this case. Therefore, we decided that 
the Plan has to pay for code 99217 billed for date of service March 17, 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: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to waive the copayment for an ultrasound. We decided that the Plan does not 
have to waive the copayment for a single-photon emission computerized tomography (SPECT) scan.  
 You asked the Plan to waive the copayment for an ultrasound and a single-photon emission computerized 
tomography (SPECT) scan. You say that you were told that the SPECT scan would have no copayment. You 
also say that there are two charges for an abdominal ultrasound on your Explanation of Benefits, but only one 
was performed. The Plan says that the copayment applied was correct. 
 
We decided that the Plan has to waive the copayment for an ultrasound.  
 
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan did not provide evidence that the ultrasound at issue was performed. 
Therefore, we decided that the Plan has to waive the copayment for an ultrasound.  
 
We also decided that the Plan does not have to waive the copayment for a SPECT scan. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as 
copayments, deductibles, and coinsurance). Your contract with the Plan clearly says that you must pay a $250 
copayment for Medicare-covered diagnostic radiology services (other than x-rays) at an in-network 
freestanding or outpatient facility. Therefore, we decided that the Plan does not have to waive the copayment 
for a SPECT scan. 
 
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. 
 
Your complaint about a Plan representative providing incorrect information by phone is not a valid appeal for 
medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does 
not permit us to make a decision about these types of complaints.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99292 billed for date of service December 
21, 2021. 
 You asked the Plan to pay for procedure code 99292. You say that this service was billed correctly and should 
be paid. The Plan denied your request. The Plan says payment for code 99292 is bundled into payment for code 
36556. 
 
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 99292 
is a column II code to column I code 36556. 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 procedure code 99292 billed for date of service December 21, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the long-term acute care hospital (LTACH) services 
provided from January 21, 2022, through February 9, 2022. 
 
You asked the Plan to pay for the services. You say that this was correctly billed. The Plan denied your request. 
The Plan says an alternate DRG was paid.  
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.   
 
In this case, you billed the inpatient services provided with principal diagnosis code A41.9. We asked our 
physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our physician reviewer found that the enrollee was 
discharged to hospice on 2/9/22. At the time of transfer from the acute care setting to the LTACH, the enrollee 
was stable and the sepsis had resolved. The review has determined that the documentation did not support the 
reported principal diagnosis code of A41.9 (sepsis, unspecified).  
 
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 the long-term acute care hospital (LTACH) services provided from January 21, 2022, through February 9, 
2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 
You asked the Plan to pre-approve Euflexxa. You say that the enrollee is not a candidate for surgery. The Plan 
denied your request. The Plan says the enrollee has already had two injections. 
 
The Plan must follow Medicare rules. Medicare rules say that repeat injections of hyaluronans for shoulder 
arthritis are limited to a single repeat course. 
 
We looked at the file and Medicare rules. The record shows that the enrollee has already received two Euflexxa 
injections for shoulder arthritis. Based on this information, we decided that Medicare rules for coverage of 
Euflexxa have not been met. Therefore, we decided that the Plan does not have to pre-approve Euflexxa.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of a pacemaker. 
 
You asked the Plan to pre-approve insertion of a pacemaker. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that implanted permanent single chamber or dual chamber 
cardiac pacemakers are covered when specific criteria are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve insertion of a pacemaker. Our reviewer 
says that the services are not medically necessary. Our physician reviewer found while you have first degree 
atrioventricular (AV) block, there is no documentation of symptomatic bradycardia. As such, there is 
insufficient documentation to support the medical necessity for insertion of a pacemaker in your clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of a pacemaker have not been met. Therefore, we decided that the Plan 
does not have to pre-approve insertion of a pacemaker.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an intraocular lens implant provided on April 19, 2022. 
 
You asked the Plan to pay for an intraocular lens implant. You say that you want the Plan to cover this service. 
The Plan denied your request. The Plan says the service at issue is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules say that if an enrollee receives an A-C IOL 
during cataract surgery, the enrollee will be responsible for the difference in cost between the A-C IOL and a 
conventional IOL.  
 
While an A-C IOL may be appropriate for you, neither the Plan nor Medicare covers the astigmatism-
correcting feature of an IOL. Therefore, we decided that the Plan does not have to pay for an intraocular lens 
implant provided on April 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the intraoral-periapical first radiographic image (D0220) and 
the resin-based composite-three surfaces, posterior (D2393) provided on April 20, 2022. 
 
You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's 
denial for payment. The Plan denied your request. The Plan says these services are not covered under your 
contractual policy. 
 
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 services provided are not among 
those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the intraoral-
periapical first radiographic image (D0220) and the resin-based composite-three surfaces, posterior (D2393) 
provided on April 20, 2022.