Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a portable ventilator (E0466). 
 
You asked the Plan to pre-approve a portable ventilator. You say that the requested device is medically 
necessary. The Plan denied your request. The Plan says the requested device does not meet criteria. 
 
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 a portable ventilator. Our reviewer says 
that the service is not medically necessary. Our physician reviewer found the medical records do not provide a 
diagnosis for which Medicare covers a home ventilator. "Mild persistent asthma" is mentioned as a diagnosis; a 
ventilator is not needed for this condition. There is no documentation of severe COPD, thoracic restrictive 
disease, or neuromuscular disease. You are not using the device. 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a portable ventilator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a portable ventilator (E0466).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the domiciliary or rest home visit provided on June 2, 2021, 
by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the domiciliary or rest home visit. You say that the services should be covered as 
you disagree with the denial. The Plan denied your request. The Plan says the services denied correctly as prior 
authorization was not obtained. 
 
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 domiciliary or rest home visit provided on 
June 2, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for drug testing provided on November 30, 2016. 
 
You asked the Plan to pay for drug testing. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says that this service has been up coded. 
 
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs 
and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to 
gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, 
eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other 
universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and 
variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control 
material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all 
sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if 
performed. 
 
We find that CPT code G0483 is supported in the medical record. Specifically, the lab report clearly shows that 
22+ drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Also, the record indicates that this provider was directed by the Plan to not 
obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the physician 
signature. Based on this information, we decided that Medicare rules for coverage of drug testing have been 
met. Therefore, we decided that the Plan has to pay for drug testing provided on November 30, 2016.  
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services provided on May 28, 2021. 
 
You asked the Plan to pay for the ambulance services. You say that it should not be your problem or obligation 
to pay for this service. The Plan denied your request. The Plan says you sent in a Direct Member 
Reimbursement without proof of payment for the service. The Plan also says that you will need to pay for the 
service and resubmit the Direct Member Reimbursement with proof of payment in order to be reimbursed for 
the service. 
 
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 ambulance services provided on 
May 28, 2021. have been met. Specifically, you need to send the Plan your request for payment along with the 
bill and documentation of any payment you have made. The record shows that you did not submit proof of 
payment and this service cannot be covered. Therefore, we decided that the Plan does not have to pay for the 
ambulance services provided on May 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on March 3, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the office visit. The Plan denied your request. The Plan says the services were 
provided out-of-network and were not approved in advance. 
 
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 visit provided on March 3, 2022, by an 
out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a routine eye exam provided on January 28, 2022. 
 
You asked the Plan to pay for a routine eye exam. The Plan denied your request. The Plan says your vision 
benefit Plan does not cover this out of network vision care service. 
 
Medicare generally does not cover routine vision services. However, the Plan offers a routine vision benefit 
that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  
 
We looked at the file and the Plan's rules. The file shows that the routine eye exam was not provided by the 
Plans vision provider. Based on this information, we decided that the Plan's rules for coverage of a routine eye 
exam have not been met. Therefore, we decided that the Plan does not have to pay for a routine eye exam 
provided on January 28, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an additional unit of initial hospital care (99223) provided on 
September 14, 2021. 
 
You asked the Plan to pay for an additional unit of initial hospital care. You say that this was a separate service. 
The Plan denied your request. The Plan says this claim is a duplicate. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
 
 
 
 
 
 
 
 
 We find that an additional unit of CPT code 99223 is not supported in the medical record. The medical record 
only supports one unit of CPT code 99223, which was previously billed by the same provider. Based on this 
information, we decided that Medicare rules for coverage of an additional unit of initial hospital care have not 
been met. Therefore, we decided that the Plan does not have to pay for an additional unit of initial hospital care 
(99223) provided on September 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapeutic exercises (97110), manual therapy (97140), 
and the chiropractic manipulative treatment (98941) rendered by the out-of-network (OON) provider from 
November 10, 2021, through January 19, 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 the services were rendered by an out-of-
network provider, without prior authorization. Additionally, the only covered chiropractic service is manual 
manipulation of the spine to correct a subluxation.  
 
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.  Additionally, Medicare rules say the only covered chiropractic service is manual manipulation of the spine to 
correct a subluxation. 
 
The 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. 
Additionally, Medicare rules and the Plan contract say the only covered chiropractic service is manual 
manipulation of the spine to correct a subluxation. 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 therapeutic exercises 
(97110), manual therapy (97140), and the chiropractic manipulative treatment (98941) rendered by the out-of-
network (OON) provider from November 10, 2021, through January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee sleeve (A4467) provided on February 2, 2022. 
 
You asked the Plan to pay for the knee sleeve. You say that you were told this item was approved, and the 
treating provider was in-network with your insurance. The Plan denied your request. The Plan says the 
National Coverage Determination (NCD) considers fabric knee sleeves to be non-reusable and not rental-type 
items, and therefore not covered items. 
 
The Plan must follow Medicare rules. Medicare rules say that fabric supports are denied, as they are non-
reusable supplies, and are not rental-type items.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the knee sleeve have not been met. Therefore, we decided that the Plan does not have to pay for the 
knee sleeve (A4467) provided on February 2, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing service provided on December 6, 2017. 
 
You asked the Plan to pay for the drug testing service. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says that this service has been up coded. 
 
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 G0480 is drug test(s), definitive, utilizing (1) drug 
identification methods able to identify individual drugs and distinguish between structural isomers (but not 
necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, 
single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., 
alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples 
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-
specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and 
mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug 
class(es), including metabolite(s) if performed. 
  
We find that CPT code G0480 is supported in the medical record. Specifically, the lab report clearly shows that 
1-7 drug classes were tested in this case. Please note, we counted the classes based on the separately billable 
tests from the CPT Handbook. Also, the record indicates that this provider was directed by the Plan to not 
obtain records. With this direction, it is inappropriate for the Plan to deny these services based on the physician 
signature. Based on this information, we decided that Medicare rules for coverage of the drug testing service 
have not been met. Therefore, we decided that the Plan has to pay for the drug testing service provided on 
December 6, 2017.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Oncology (urothelial), mRNA, gene expression profiling by 
real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing 
urine, algorithm reported as a risk score for having urothelial carcinoma (0012M) provided on November 16, 
2021 by an out-of-network (OON) provider. 
 
You asked the Plan to pay for Cxbladder Detect. You say that you are appealing the denial of coverage for the 
Cxbladder Detect test. The Plan denied your request. The Plan says enrollees must receive their medical 
services from an in-network provider with the exception being urgent or emergent services. Non-emergent 
services with non-contracted providers require prior authorization before services being rendered.  
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 Oncology (urothelial), mRNA, gene expression 
profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), 
utilizing urine, algorithm reported as a risk score for having urothelial carcinoma (0012M) provided on 
November 16, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is 
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does 
not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found there are no services available at the LTACH that the enrollee requires that are not 
available at the health care setting being offered by the health plan. The health plan has approved ongoing care 
in the current acute care setting. The requested LTACH services are not medically necessary, reasonable, and 
appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only 
on an inpatient 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient office visit rendered on January 17, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99204 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. 
 
In this case, the CPT Code Manual definition of code 99204 is office or other outpatient visit for the evaluation 
and management of a new patient, which requires a medically appropriate history and/or examination and 
moderate level of medical decision making. When using time for code selection, 45-59 minutes of total time is 
spent on the date of the encounter.  
 
We find that CPT code 99204 is not supported in the medical record. Specifically, the file shows that the 
enrollee was seen by this provider group within the past three years; therefore, a new patient office visit does 
not apply. Based on this information, we decided that Medicare rules for coverage of these services have not 
been met. Therefore, we decided that the Plan does not have to pay for the new patient office visit rendered on 
January 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical services rendered on December 23, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure codes 49440 and 77001 are not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 49440 is insertion of gastrostomy tube, percutaneous, 
under fluoroscopic guidance including contrast injection(s), image documentation and report. The definition of 
code 77001 is fuoroscopic guidance for central venous access device placement, replacement (catheter only or 
complete), or removal (includes fluoroscopic guidance for vascular access and catheter manipulation, any 
necessary contrast injections through access site or catheter with related venography radiologic supervision and 
interpretation, and radiographic documentation of final catheter position) (List separately in addition to code 
for primary procedure). 
 We find that CPT codes 49440 and 77001 are not supported in the medical record. Specifically, there is no 
documentation of insertion of gastrostomy tube, percutaneous under fluoroscopic guidance to support code 
49440. Given that code 49440 is not supported, component code 77001 is also not supported. Based on this 
information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we 
decided that the Plan does not have to pay for the surgical services rendered on December 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiofrequency ablation (RFA) of the sacroiliac (SI) joint 
rendered on January 26, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are 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 pay for these services. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found you have a history of sacroilitis and low 
back and hip pain. The RFA of the SI joint is considered experimental in nature and was 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pay for radiofrequency ablation (RFA) of the sacroiliac (SI) joint rendered on January 26, 2022.