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

 
We decided that the Plan does not have to pay for procedure code 99152 billed for December 22, 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 99152 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 99152 is moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 We find that CPT code 99152 is not supported in the medical record. Specifically, the records do not indicate 
the intra-service time for moderate sedation services. 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 procedure code 99152 billed for December 22, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466) 
 
You asked the Plan to pre-approve a ventilator. 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 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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment 
selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with average 
volume assured pressure support (AVAPS) capability and failure of such a device has not been documented. 
The plan has indicated coverage for such a device is available upon request. The elements of the coverage 
criteria are not satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466)
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 enrollee currently meets long term 
acute care admission criteria under Centers for Medicare & Medicaid Services (CMS) guidelines. The Plan 
denied your request. The Plan says the LTACH services requested do not meet the requirements for approval. 
 
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 in this case the enrollee was admitted with seizures secondary to stroke and has had a 
complicated hospital course. The record indicates that the enrollee is improving but still requires acute care 
services before transitioning to a lower level of care. Our reviewer found that the enrollee continues to receive 
acute care services, and these have not been denied. Our physician reviewer also found that the medical record 
does not indicate that the enrollee requires services that they are not currently receiving but that would be 
available at the LTACH facility. 
 
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: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (87801, 87511, 87640, 87798, 87500, 87653 and 
87481) provided on February 23, 2023. 
 
You asked the Plan to pay for laboratory services.. You say that these services were necessary and are 
supported in the medical record. The Plan denied your request. The Plan says that these services should be 
billed with one single code. 
 
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 cited a coverage article/determination which does not 
have jurisdiction over state where these services were performed, and we were unable to find this information 
in a determination which applies to the state in question. In addition, many of the services at issue were 
reported with the -59 modifier, indicating that they were provided as separate and distinct services. It does not 
appear that the Plan has performed a review to determine whether the reported modifiers were appropriate or 
not. The Plan has not fully substantiated their denial in this case. Therefore, we decided that the Plan has to pay 
for laboratory services (87801, 87511, 87640, 87798, 87500, 87653 and 87481) provided on February 23, 
2023.  
 
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 pay for eight additional units of procedure code 77300 rendered on 
May 15, 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 while the documentation does support that excess units were provided, there was no specific 
rationale given for why the additional units needed to be performed. 
 
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 77300 is "Basic radiation dosimetry calculation, central 
axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, 
calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when 
prescribed by the treating physician." 
 
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 enrollee is being planned and 
treated with adaptive radiotherapy. There is documentation of a a replan on the date of service under dispute. 
The records include a check box form that documents that the current plan would decrease coverage below a 
clinically acceptable level and would increase dose to normal tissues to above clinically acceptable levels  
either of which would support an adaptive plan. Radiation records include treatment plan reports and records, 
and documentation of orders and electronic approval of the prescription and plan. The signed plan documents 
the physician approval of the IMRT plan and therefore the monitor unit calculations. This is sufficient to 
document physician involvement in the treatment planning process. From the treatment planning records there 
are 18 beams with 18 beam calculations. Generally the 77300 billing code is considered to be medically 
necessary for each treatment port/gantry angle though a maximum of 10 units of 77300 (based upon 
recommendations by the ACR and ASTRO) are allowed per course. 
 
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 eight additional units of procedure code 77300 rendered on May 15, 2023.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve percutaneous image guided lumbar decompression 
(PILD) (0275T). 
 
You asked the Plan to pre-approve PILD. 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 must follow Medicare rules. Medicare rules say that effective for dates of service specified below, the 
Centers for Medicare & Medicaid Services (CMS) has determined that PILD will be covered by Medicare 
when provided in a clinical study under section 1862(a)(1)(E)of the Social Security Act (the Act) through 
Coverage with Evidence Development (CED) for beneficiaries with LSS who are enrolled in an approved 
clinical study that meets the criteria. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of PILD have not been met. Therefore, we decided that the Plan does not have to pre-approve 
percutaneous image guided lumbar decompression (PILD) (0275T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF services to regain their 
prior level of functioning. The Plan denied your request. The Plan says the request is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
  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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found that the enrollees medical problems are stable and there are no complex nursing or 
rehabilitation needs. While the medical record supports a need for physical or occupational therapy, there is no 
documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 
level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that admission to an IRF is medically necessary. The 
Plan denied your request. The Plan says admission to an IRF does not meet criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 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 IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee is medically improved and stable and does not need physician's 
supervision three (3) times a week in an IRF. No nursing needs identified or documented. At the current 
functional level, the enrollee does not need specialized and intensive therapies consisting of at least 3 hours of 
therapy per day at least five (5) days per week with multidisciplinary approach in an IRF. Document does not 
support necessity for admission to an IRF. The complexity of the enrollee's medical, rehab, and nursing needs 
(combined complexity) does not require an acute hospital inpatient rehab stay with an interdisciplinary 
approach to rehabilitative care. The enrollee's rehab needs can be safely provided in an alternate and low 
intensity setting such as in a skilled nursing facility (SNF). 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (PCD) billed with code 
E0676 for September 6, 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 covered. 
 
The Plan must follow Medicare rules. The rules say that a pneumatic compression device (PCD) that provides 
intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is not 
covered.  
 
We looked at the file and Medicare rules. The services at issue are a PCD coded E0676. These services are not 
covered by Medicare. Therefore, we decided that the Plan does not have to pay for the pneumatic compression 
device (PCD) billed with code E0676 for September 6, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 49450 billed for April 19, 2023. 
 
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 service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 49440 
provided on April 17, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code 49450 billed for 
April 19, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the urgent care visit provided on February 
18, 2023. 
 
You asked the Plan to waive the copayment for the urgent care visit. You say that services were not rendered 
on this date. 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 a $40 
copayment for urgently needed services. 
 
You have been asked to pay a $40 copayment for the urgent care visit. This item/service falls within the 
urgently needed services 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 medical records show services were provided on this date. Therefore, we decided that 
the Plan does not have to waive the copayment for the urgent care visit provided on February 18, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 86077 billed for date of service March 2, 
2023.  
 You asked the Plan to pay for procedure code 86077. You say that you have billed the services at issue 
correctly. The Plan denied your request. The Plan says the number of units billed exceeds the maximum 
allowed. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of 
procedure code 86077 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 86077 billed for date of service March 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Infrared light therapy provided on February 2, 2023. 
 
You asked the Plan to pay for Infrared light therapy. The Plan denied your request. The Plan says Infrared 
therapy is considered not reasonable and necessary by Medicare and is excluded from coverage. 
 
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary.  
 
We looked at the file and Medicare rules. Medicare says that there is sufficient evidence to conclude the use of 
Infrared therapy devices and any related accessories is not reasonable and necessary. Therefore, we decided 
that the Plan does not have to pay for Infrared light therapy provided on February 2, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diffusing capacity (94729), gas dilution or washout for 
determination of lung volumes and, when performed, distribution of ventilation and closing volumes (94727), 
and breathing capacity test (94010) provided on August 17, 2021. 
 
You asked the Plan to pay for the diffusing capacity, gas dilution or washout, and breathing capacity test. You 
say that you do not believe the amount in question is your responsibility, and you believe your claim was 
processed incorrectly by the Plan. The Plan denied your request. The Plan says the services were allowed at the 
rate the primary carrier allowed. 
 
 
 
 The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has fulfilled their 
obligation because your primary insurance carrier already paid more than the Medicare allowed amount. As the 
secondary insurer, the Plan cannot be held responsible for the remaining amounts for the diffusing capacity, gas 
dilution or washout, and breathing capacity test. Therefore, we decided that the Plan does not have to pay for 
the diffusing capacity (94729), gas dilution or washout for determination of lung volumes and, when 
performed, distribution of ventilation and closing volumes (94727), and breathing capacity test (94010) 
provided on August 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on December 12, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the claim is not 
payable as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 indicates 
that the two conditions cannot occur together.  
 
We looked at the file and Medicare rules. The claim in this case was billed with diagnosis codes R25.1 and 
G20. Diagnosis code R25.1 has an Excludes1 note and cannot be billed with diagnosis code G20. 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 services provided on December 12, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the 
Plan's 60-trip limit. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you recently had surgery and 
need additional routine transportation. The Plan denied your request. The Plan says you have exhausted your 
transportation benefit. 
 Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plans coverage rules apply in this 
case. The Plan covers a maximum of 60 trips per year.  
 
We looked at your request, the records in the case file, and the rules. Based on this information, we decided 
that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we 
decided that the Plan does not have to pre-approve additional trips for routine transportation beyond the Plan's 
60-trip limit.