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

 
We decided that the Plan does not have to pay for definitive drug testing (G0483) billed for date of service 
February 15, 2023. 
 
You asked the Plan to pay for drug testing. You say that these services were necessary and are supported in the 
medical record. The Plan denied your request. The Plan says the code reported does not accurately reflect the 
services provided. Another code would be more appropriate in this case. 
 
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, 22 or more drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0483 is not supported in the medical record. Specifically, the records support that 
drugs from only 19 drug classes were tested in this case. A different code would be more accurate for the 
services provided. Based on this information, we decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for definitive drug testing (G0483) 
billed for date of service February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 96365 and 96366 billed for date of service 
February 27, 2023. 
 You asked the Plan to pay for the billed services. You say that the enrollee was seen for problems with 
diabetes. The Plan denied your request. The Plan says the billed codes 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. 
 
We find that outpatient intravenous insulin therapy, billed withs CPT code 96365 and 96366, is not a covered 
Medicare benefit. Based on this information, we decided that Medicare rules for coverage of the billed services 
have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 96365 and 
96366 billed for date of service February 27, 2023.
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 the services are medically necessary. The Plan 
denied your request. The Plan says ongoing skilled care can be provided in an alternative setting.  
 
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 you do not require treatment by multiple therapies. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 93000, defined as electrocardiogram, routine with at 
least 12 leads; with interpretation and report, 71046, defined as radiologic examination, chest; 2 views, R0075, 
defined as transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, more than 1 patient seen, and Q0092, defined as set-up of portable x-ray equipment 
performed on March 20, 2023. 
 
You asked the Plan to pay for 93000, 71046, R0075, and Q0092. You say that 93000, 71046, R0075, and 
Q0092 should be covered as billed because they are supported in the documentation. The Plan denied your 
request. The Plan says 93000 is denied because the records do not contain documentation that an 
electrocardiogram was done. 71046, R0075, and Q0092 are denied because there are discrepancies with the 
billed POS. 
 
The Plan must follow Medicare rules. Medicare rules say that providers/suppliers must report services 
correctly. Medicare rules also say that claims must be billed with the appropriate POS.  
 
We looked at the file and Medicare rules. We confirmed there is no interpretation and report of an 
electrocardiogram signed by the provider included in the documentation, therefore 93000 is not supported. 
Codes 71046, R0075, and Q0092 were billed with POS 12, indicating the services were rendered at the 
enrollees home. However, the address listed on the claim and the address listed on the procedure note do not 
match the enrollee's home address, therefore the information provided is not sufficient to confirm that the 
services were rendered at the enrollees home. Based on this information, we decided that Medicare rules for 
coverage for codes 93000, 71046, R0075, and Q0092 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 93000, defined as electrocardiogram, routine with at least 12 leads; with 
interpretation and report, 71046, defined as radiologic examination, chest; 2 views, R0075, defined as 
transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or 
location, more than 1 patient seen, and Q0092, defined as set-up of portable x-ray equipment performed on 
March 20, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the oxygen concentrator and portable oxygen tank. 
 
You asked the Plan to pre-approve the oxygen concentrator and portable oxygen tank. You say that the 
requested items are a medical necessity. The Plan denied your request. The Plan says we reviewed the records 
provided and the enrollee does not meet coverage for the oxygen concentrator and portable oxygen tank.  
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with hypoxemia who meet certain blood gas evidence requirements. In reviewing the arterial PO2 
levels and the arterial oxygen saturation percentages, variations in oxygen measurements that may result from 
such factors as the patient's age, the patients skin pigmentation, the altitude level, or the patient's decreased 
oxygen carrying capacity, must be taken into account. For patients who do not exhibit hypoxemia according to 
the above criteria, oxygen may be coverable when medically reasonable and necessary for patients who do not 
have a non-covered indication. 
 
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 oxygen concentrator and portable 
oxygen tank  Our reviewer says that the home stationary and portable oxygen are not medically necessary. Our 
physician reviewer found the enrollee was seen in an emergency department for a fractured distal femur on 
February 7, 2023. The oxygen saturation was noted to be 100%. It is not indicated whether the enrollee was on 
supplemental oxygen. There are no other qualifying oxygenation data to support the need for supplemental 
oxygen. 
 
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 oxygen concentrator and portable oxygen tank  have not been met.  
Therefore, we decided that the Plan does not have to pre-approve the oxygen concentrator and portable oxygen 
tank.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve a PET scan concurrently with a CT scan from the skull base to 
mid-thigh. 
 
You asked the Plan to pre-approve the PET/CT scan. You say that you are appealing with supporting records. 
The Plan denied your request. The Plan says that the request is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are 
medically necessary.  
 
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 PET/CT scan. Our reviewer says 
that the request is medically necessary. Our physician reviewer found that PET scan has been used to look for 
recurrent disease. Given that it has been FDG avid and been followed with PET scan particularly after their left 
hip replacement surgery in 2022, it appears reasonable and necessary to continue surveillance for now using 
PET scan. 
 
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 PET/CT scan have been met. Therefore, we decided that the Plan has to pre-
approve a PET scan concurrently with a CT scan from the skull base to mid-thigh.  
 
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: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for a cleaning (D1110) provided on May 22, 2023. 
 
You asked the Plan to pay for the cleaning. You say that you went in four days early for your routine cleaning. 
You say it should start at the new enrollment of this year and not go off of the prior year. The Plan denied your 
request. The Plan says that your benefit for the requested item or service has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. The rules say that Medicare health plans must disclose benefit limitations in clear accurate 
terms. The Plan contract does not clearly disclose the benefit limitations for cleanings. The Evidence of 
Coverage does not clearly disclose that you can get two cleanings at any point in one calendar year, or if the 
cleanings have to be six months part. 
 
The Plan has not disclosed in clear accurate terms, the benefits offered, including applicable conditions and 
limitations. Therefore, we decided that the Plan has to pay for a cleaning (D1110) provided on May 22, 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 pre-approve Intra-Dialytic Parenteral Nutrition (IDPN). 
 
You asked the Plan to pre-approve IDPN. 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 for parenteral nutrition to be considered reasonable 
and necessary, the treating practitioner must document that enteral nutrition has been considered and ruled out, 
tried and been found ineffective, or that EN exacerbates gastrointestinal tract dysfunction. 
 
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 IDPN. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the review has determined that the 
documentation submitted does not demonstrate that the enrollee has a permanent gastrointestinal (GI) 
impairment, or they are unable to take food and liquids by mouth. The enrollee does not meet the coverage 
criteria.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IDPN have not been met. Therefore, we decided that the Plan does not have to 
pre-approve Intra-Dialytic Parenteral Nutrition (IDPN).
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from October 28, 2022, to 
November 26, 2022. 
 You asked the Plan to pay for the home health services. You say that you have supplied the required NOA. The 
Plan denied your request. The Plan says the NOA was not received timely. As such, this final claim was 
correctly denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is October 28, 2022. The NOA was not received by the Plan until February 
13, 2023. As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be 
made on this claim. Therefore, we decided that the Plan does not have to pay for home health services provided 
from October 28, 2022, to November 26, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from February 9, 2023, to 
March 8, 2023. 
 You asked the Plan to pay for the home health services. You say that all of the claim lines are covered charges. 
The Plan denied your request. The Plan says the NOA was not received. As such, this final claim was correctly 
denied.  
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the NOA was not received by the Plan. As such, no payment can be made on this claim. Therefore, 
we decided that the Plan does not have to pay for home health services provided from February 9, 2023, to 
March 8, 2023.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve massage therapy services. 
 
You asked the Plan to pre-approve the therapy services. You say that the services are medically necessary as a 
part of approved physical therapy services. The Plan denied your request. The Plan says the requested services 
are not medically reasonable and necessary. 
 The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 
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 therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found you have previously been treated with outpatient therapies and should 
be independent with a home exercise program. There is no documentation that would indicate massage therapy 
is medically necessary for treatment of osteoarthritis of the shoulders. The additional therapy services are not 
an appropriate duration and frequency for treatment of your medical condition and therefore are not medically 
necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve massage therapy services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140), first 
intraoral periapical x-ray (D0220), two additional intraoral periapical x-rays (D0230 x2), and simple extraction 
(D7140) provided on May 4, 2023. 
 You asked the Plan to pay for the problem focused limited oral evaluation, intraoral periapical x-rays, and 
simple extraction. You say that some of the claim should be reimbursed. You also say that you are living on 
social security, and it does not leave you much when you have to pay this type of expense.  The Plan denied 
your request. The Plan says these services are not covered under your contract under any normal 
circumstances. 
 
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 requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
problem focused limited oral evaluation (D0140), first intraoral periapical x-ray (D0220), two additional 
intraoral periapical x-rays (D0230 x2), and simple extraction (D7140) provided on May 4, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 75630-26-59 billed for date of service March 31, 2023. 
 
You asked the Plan to pay for code 75630-26-59. You say that code 75630 is for a separate aortogram that was 
performed during the cardiac procedure. The report describes that these are separate and significant procedures. 
The 59 modifier was appended to show it was separate. The Plan denied your request. The Plan says the use of 
the 59 modifier to allow for separate payment of code 75630-26-59 is not supported by the medical record. 
This code is included in code 93460. The records don't support that the service was distinct or independent 
from code 93460. 
 The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 code 75630-26-59. Our reviewer says that 
the use of the 59 modifier to allow for separate payment of code 75630-26-59 is not supported by the medical 
record. Our physician reviewer found the provider reported this procedure code with appended modifier 59 
distinct procedural service to bypass an NCCI Edit with CPT 93460.  However, the procedure report does not 
include documentation to support a distinct procedural service.  This service was performed through same entry 
point, and therefore would be inclusive to the more comprehensive procedure.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 75630-26-59 have not been met. Therefore, we decided that the Plan does 
not have to pay for code 75630-26-59 billed for date of service March 31, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve bilateral mastectomy for gynecomastia with free nipple 
graft. 
 
You asked the Plan to pre-approve bilateral mastectomy for gynecomastia with free nipple graft. You say that 
free-floating silicone is recognized as a harmful substance that should be removed. The Plan denied your 
request. The Plan says this procedure is considered cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.   
 
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 bilateral mastectomy for gynecomastia 
with free nipple graft. Our reviewer says that the criteria for coverage have not been met.  Our reviewer found 
although records report Klinefelter's syndrome, provided records in this case do not document any evaluation 
for pathological causes of gynecomastia or medical treatment for gynecomastia. Records note back pain 
attributed to the gynecomastia but do not clarify that the pain has a clinically significant impact upon activities 
of daily living, the clinical symptoms are refractory to a trial of analgesics or anti-inflammatory agents or that 
there are significant clinical manifestations when the excessive breast weight adversely affects the supporting 
structures of the shoulders, neck, and trunk. Overall, the provided records in this case are inadequate to confirm 
that the requested surgery meets all criteria for reasonable, necessary, safe, and effective for the patient.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of bilateral mastectomy for gynecomastia with free nipple graft have not been met. 
Therefore, we decided that the Plan does not have to pre-approve bilateral mastectomy for gynecomastia with 
free nipple graft.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on November 4, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly.  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the lab services have not been met. Specifically, this claim was billed with the laboratory POS 
code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that 
the Plan does not have to pay for the lab services provided on November 4, 2022.