Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional moderate sedation time provided on date of 
service April 19, 2023, billed with code 99153. 
 
You asked the Plan to pay for procedure code 99153. You say that this service was medically necessary. The 
Plan denied your request. The Plan says code 99153 is not payable in the facility setting.  
 
Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE only code and that PE are not 
payable to the physician for services provided in the facility setting.   
We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment to the 
physician for CPT code 99153 when performed in the facility setting. Therefore, we decided that the Plan does 
not have to pay for the additional moderate sedation time provided on date of service April 19, 2023, billed 
with code 99153.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve methotrexate (J8310). 
 
You asked the Plan to pre-approve the medication. You say that you have been successfully taking 
methotrexate with positive results. The Plan denied your request. The Plan says the medication is not covered 
as a medical benefit under the Plan. 
 The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve methotrexate (J8310).  
 
Benefits for the medication 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 pay for procedure codes 36556, 76937, and 93042 rendered on 
August 4, 2022. 
 
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 providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 In this case, the CPT Code Manual definition of the denied codes is: 
 
CPT 36556: 
 
Insertion of non-tunneled centrally inserted central venous catheter; age 5 years or older 
 
CPT 76937: 
 
Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, 
documentation of selected vessel patency, concurrent realtime ultrasound visualization of vascular needle 
entry, with permanent recording and reporting (List separately in addition to code for primary procedure) 
 
CPT 93042: 
 
Rhythm electrocardiogram (ECG), 1-3 leads; interpretation and report only 
 
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 says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the medical records provided do 
not include documentation that a central line placed under (or without) ultrasound guidance was 
performed. The postintubation x-ray does not report the presence of a central line. 
 
Additionally, in this case, we have confirmed that code 93042 is a column II code to column I code 99291 with 
a modifier indicator of 0. The column II code is therefore not payable. Based on the claim submitted, Medicare 
billing criteria have not been met. 
 
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 procedure codes 36556, 76937, and 93042 rendered on August 4, 2022.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to pre-approve a colonoscopy (45378). 
 
You asked the Plan to pre-approve a colonoscopy. You say that the requested service is a medical necessity for 
the enrollee. The Plan denied your request. The Plan says that the requested service is not medically necessary. 
 
The Plan follows Medicare rules. The rules say that Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy is 
covered for the indications listed in the Medicare rules section of this letter. 
 
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 colonoscopy. Our reviewer says that 
the requested colonoscopy is medically reasonable and necessary in this case. Our physician reviewer found 
that the requested service is a clearly indicated colonoscopy for the evaluation of iron deficiency anemia (IDA) 
in the setting of a positive Fecal Immunochemical Test (FIT) and for colon cancer screening. 
 
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 colonoscopy have been met. Therefore, we decided that the Plan has to pre-
approve a colonoscopy (45378).  
 
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 reduce the coinsurance for a Medicare Part B drug injection provided 
on March 30, 2023. 
 
You asked the Plan to reduce the coinsurance for a Medicare Part B drug injection. You say that you disagree 
with the cost share applied and cannot afford to pay. The Plan denied your request. The Plan says this cost 
sharing was charged correctly. 
 
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 20% 
coinsurance for Medicare Part B prescription drugs. 
 
You have been asked to pay 20% coinsurance for a Medicare Part B drug injection. This item/service falls 
within the Medicare Part B prescription drugs benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to 
pay when you enrolled in the Plan. The total you owe is $411.60, which is 20% of the allowed amount for 
Medicare Part B drug injections ($2,058 allowed x 20% = $411.60). Therefore, we decided that the Plan does 
not have to reduce the coinsurance for a Medicare Part B drug injection provided on March 30, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the office visit and the ECG provided on 
April 24, 2023, by an OON provider.  
 You asked the Plan to provide reimbursement for the office visit and the ECG. You say that you are requesting 
reconsideration of the denied claim. The Plan denied your request. The Plan says these services were not 
authorized. 
 
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 provide reimbursement for care from out-of-network providers only in cases 
involving emergencies, out of area urgent care and pre-approved care. The Plan has a POS option to cover 
certain out-of-network services. You must obtain prior authorization from the Plan before seeking 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 provide reimbursement for these 
items/services. Therefore, we decided that the Plan does not have to provide reimbursement for the office visit 
and the ECG provided on April 24, 2023, by an OON provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a home visit, and related services provided on April 21, 
2023. 
 
You asked the Plan to pay for a home visit, and related services. You say that the enrollee was in a nursing 
facility and should not have needed an authorization. The Plan denied your request. The Plan says that 
unauthorized, out-of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for a home visit, and related 
services provided on April 21, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the coinsurance for the hand surgery provided on March 03, 
2023. 
 
You asked the Plan to reduce the coinsurance for the hand surgery. You say that you initially received an 
explanation of benefits with a different coinsurance amount. The Plan denied your request. The Plan says this 
cost sharing was charged correctly. 
 
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 20% 
coinsurance for in-network outpatient surgery provided at an outpatient hospital. 
 
You have been asked to pay 20% coinsurance for the hand surgery. This item/service falls within the in-
network outpatient surgery provided at an outpatient hospital benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual 
obligation you agreed to pay when you enrolled in the Plan. The total you owe is $534.28 ($2,671.43 allowed 
amount x 20% coinsurance = $534.28). Therefore, we decided that the Plan does not have to reduce the 
coinsurance for the hand surgery provided on March 03, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to provide reimbursement for the office visit, the cervical cancer 
screening, the cytopathology screening, and the transvaginal ultrasound provided on April 23, 2023, by an 
OON provider.  
 
You asked the Plan to provide reimbursement for the services. You say that you are requesting reconsideration 
of the denied claim. The Plan denied your request. The Plan says these services were not authorized. 
 
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 provide reimbursement 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 provide reimbursement for these 
items/services. Therefore, we decided that the Plan does not have to provide reimbursement for the office visit, 
the cervical cancer screening, the cytopathology screening, and the transvaginal ultrasound provided on April 
23, 2023, by an OON provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (procedure code 0326U) rendered on 
February 14, 2023. 
 
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 denied code remains 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 0326U is "Targeted genomic sequence analysis panel, 
solid organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence 
variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor 
mutational burden." 
 
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 says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that the code is not supported because 
the results of all 83 genes are not individually reported here and the negatives are grouped into a not detected 
category. 
 
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 laboratory services (procedure code 0326U) rendered on February 14, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for wound care supplies (A6196, A6219) provided on April 24, 
2023. 
 
You asked the Plan to pay for the wound care supplies. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 The record does not contain a valid proof of delivery to support the supplies provided in this case. There is no 
itemized invoice. The record shows that the Plan made several attempts to obtain the necessary documentation 
without success. Therefore, we decided that the Plan does not have to pay for wound care supplies (A6196, 
A6219) provided on April 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (85045, 87186) provided on April 13, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the records do not support the billed services. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 85045, & 87186 are not supported in the medical record. Specifically, the lab order 
provided does not include the billed tests. 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 lab 
services (85045, 87186) provided on April 13, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy provided on August 01, 2022, to August 17, 
2022. 
 
You asked the Plan to pay for physical therapy. You say that you are requesting reconsideration stating that 
there is an approved authorization on file for the services and you are requesting that the claim be reprocessed 
and paid. The Plan denied your request. The Plan says that unauthorized, out-of-network care is not covered. 
 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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for physical therapy 
provided on August 01, 2022, to August 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (G0482) provided on January 5, 2023. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the documentation does not support the billed service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code G0482 is Drug Testing, definitive, 15-21 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the record does not show 
that 15-21 drug classes were tested. 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 lab services 
(G0482) provided on January 5, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation provided on March 20, 2023. 
 
You asked the Plan to pay for the telephone evaluation. You say that the enrollee was in a nursing home at the 
time services were rendered. The Plan denied your request. The Plan says that unauthorized, out-of-network 
care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay 
for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for the telephone evaluation 
provided on March 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 94200, 94375, 94726, 94729 and 99204 
billed for date of service February 1, 2023. 
 
You asked the Plan to pay for procedure codes 94200, 94375, 94726, 94729 and 99204. You say that you have 
billed the services at issue correctly. The Plan denied your request. The Plan says rules for payment have not 
been met. 
 
The Plan follows Medicare rules. The rules say that providers must comply with ICD-10-CM coding 
guidelines. Certain Z codes/categories may only be reported as the principal/first-listed diagnosis, except when there are multiple encounters on the same day and the medical records for the encounters are combined.  
 
In this case, the services at issue were reported with secondary diagnosis code Z01.811. We have confirmed 
that diagnosis code Z01.811 may only be reported as the principal diagnosis. Based on this information, we 
decided that the Medicare billing rules for procedure codes 94200, 94375, 94726, 94729 and 99204 have not 
been met. Therefore, we decided that the Plan does not have to pay for procedure codes 94200, 94375, 94726, 
94729 and 99204 billed for date of service February 1, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 7, 2023, billed with 
codes 87481, 87491, 87500, 87563, 87640, 87641, 87653, & 87798. 
 
You asked the Plan to pay for the genetic testing billed. You say that these services were medically necessary. 
The Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 7, 2023, billed with codes 87481, 87491, 87500, 87563, 87640, 87641, 87653, & 87798.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve intracardiac catheter ablation. 
 
You asked the Plan to pre-approve the services. You say that this should be paid for. The Plan denied your 
request. The Plan says the records indicate hyperthyroidism, a reversible cause of atrial fibrillation. 
 
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 the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found that recent randomized clinical studies have supported the role of catheter ablation for the treatment of 
symptomatic atrial fibrillation as an acceptable first-line alternative to medications in the treatment of patients 
with this arrhythmia. However, the enrollees physician describes her as asymptomatic on a recent office visit. 
As such, based on the documentation submitted, electrophysiologic evaluation and catheter ablation would not be considered medically appropriate and necessary in this enrollees 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve intracardiac catheter ablation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with components. 
 
You asked the Plan to pre-approve Group 3 power wheelchair. You say that the enrollee needs this to live at 
home safely and securely. The Plan denied your request. The Plan says the enrollee does not have a qualifying 
diagnosis for a Group 3 power wheelchair. 
 
The Plan must follow Medicare rules. The rules say that a Group 3 power wheelchair can be covered only for 
enrollees who have a mobility limitation that is due to: 
 
1. A neurological condition; 
 
2. Myopathy; or  
3. Congenital skeletal deformity. 
 
The file does not show that the enrollee has a mobility limitation that is due to a neurological condition, 
myopathy or congenital skeletal deformity. Therefore, we decided that the Plan does not have to pre-approve a 
Group 3 power wheelchair with components.