Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Favorable

 
We decided that the Plan has to pay for ambulance transportation services (A0427, A0425) provided on 
November 25, 2022. 
 
You asked the Plan to pay for ambulance services. You say that there services were necessary and should be 
paid. The Plan denied your request. The Plan says that these services were not medically necessary and are 
therefore denied. 
 
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 denied payment for these services only on the basis that 
they were submitted with the GY modifier. Although this modifier often means that the provider feels that 
these services do not meet Medicare criteria, services billed with the GY modifier are still subject to review and 
are not automatically denied. The Plan has not forwarded any medical records for these services, nor is there 
any evidence that any medical records were requested by the Plan for review. Without the medical records, we 
cannot verify whether or not these services were medically necessary or whether the modifier was used 
appropriately. The Plan has failed to substantiate their denial by requesting/collecting and reviewing the 
relevant records to determine whether these services were necessary. Therefore, we decided that the Plan has to 
pay for ambulance transportation services (A0427, A0425) provided on November 25, 2022.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for subsequent nursing facility care provided on March 24, 2023. 
 
You asked the Plan to pay for subsequent nursing facility care. You say that the services were medically 
necessary. 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 subsequent nursing 
facility care provided on March 24, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Cxbladder Triage test (81479) provided October 8, 2022. 
 
You asked the Plan to pay for the genetic testing. You say that you are asking for review of this enrollee's case 
and authorize coverage for the Cxbladder Triage test. The Plan denied your request. The Plan says the 
Cxbladder panel remains unproven at this time.  
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 We looked at the file and Medicare rules. The Cxbladder panel remains unproven at this time.  Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for Cxbladder Triage test (81479) provided October 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health care provided from January 9, 2021, to February 
5, 2021. 
 
You asked the Plan to pay for home health services. You say that this was medically necessary. The Plan 
denied your request. The Plan says the services were not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is 
medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for 
home health care services. 
 
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 home health services. Our reviewer says that 
the services were not medically reasonable and necessary. Our physician reviewer found the enrollee did not 
have documented skilled nursing or therapy needs. The enrollee is not noted to have had an acute illness or 
injury. The enrollee is noted to having been functioning at or near baseline. Home health services were not 
shown to have been medically necessary or reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home health services have not been met. Therefore, we decided that the Plan 
does not have to pay for home health care provided from January 9, 2021, to February 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service provided on February 10, 2023. 
 
You asked the Plan to pay for the ambulance service. You say that this was the only safe way to transfer the 
enrollee. 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 ambulance service 
provided on February 10, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiological services provided on January 18, 2023, billed 
with codes 74240, 74230, 72040, 70100, 70310, and 71045. 
 
You asked the Plan to pay for the radiology services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says this is a non-covered service. 
 
The Plan must follow Medicare rules. Medicare rules say that procedures requiring the administration of a 
substance to the patient or injection of a substance into the patient and/or special manipulation of the patient are 
not covered under portable x-ray provision.   
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the radiology services provided have not been met. The service provided is a barium swallow study 
and includes the administration of a substance to the patient. Therefore, we decided that the Plan does not have 
to pay for radiological services provided on January 18, 2023, billed with codes 74240, 74230, 72040, 70100, 
70310, and 71045.
Appeal type: Outpatient Therapies
Decision: Favorable

 
We decided that the Plan has to pay for the speech therapy services provided on November 10, 2021. 
 
You asked the Plan to pay for the speech therapy services. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says that the services are not payable. 
 
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. Review of the file shows that the Plan has denied these services stating that this 
service does not meet the coverage requirements in the applicable Local Coverage Determination (LCD) or 
National Coverage Determination (NCD). However, the documentation did not include the LCD or NCD used 
by the Plan to support this denial. No other denial rationale was provided. The Plan did not substantiate their 
denial. Therefore, we decided that the Plan has to pay for the speech therapy services provided on November 
10, 2021.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a CardioMEMs device (33289).  
 
You asked the Plan to pre-approve a CardioMEMs device. You say that the clinical value and effectiveness of 
the CardioMEMs device has not been demonstrated in the peer-reviewed literature. The Plan denied your 
request. The Plan says this service is medically reasonable and 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 pre-approve a CardioMEMs device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that there remains a dearth of randomized, blinded clinical studies examining long-term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system 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 a CardioMEMs device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a CardioMEMs device (33289).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the breast ultrasound provided on April 11, 
2023. 
 
You asked the Plan to waive the copayment for the breast ultrasound. You say that you were not told there 
would be a copayment for the ultrasound. 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 in-network outpatient diagnostic tests, including ultrasounds. 
 
You have been asked to pay a $40 copayment for the breast ultrasound. This item/service falls within the in-
network outpatient diagnostic tests, including ultrasounds 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. Therefore, we decided that the Plan does not have 
to waive the copayment for the breast ultrasound provided on April 11, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code G0481 for date of service March 22, 2022, to April 1, 
2022. 
 
You asked the Plan to pay for code G0481. You say that you disagree with the Plan's denial. The Plan denied 
your request. The Plan says the services billed 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 G0481 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; 8-14 
drug class(es), including metabolite(s) if performed. 
 
We find that CPT code G0481 is not supported in the medical record. Specifically, the documentation shows 
that 30 drug classes were tested. This means there is a more appropriate code to be billed for the services 
rendered. Based on this information, we decided that Medicare rules for coverage of code G0481 have not been 
met. Therefore, we decided that the Plan does not have to pay for code G0481 for date of service March 22, 
2022, to April 1, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an expandable controller (E2311) for the enrollee.
You asked the Plan to pre-approve an expandable controller. You say that this controller is needed to keep the enrollee independent with the power wheelchair. The Plan denied your request. The Plan says that there is no need to control 2 or more power options through the joystick.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for an expandable controller. Our Medical Director states that the documentation supports that the enrollee has upper limb strength and function that are adequate to be able to control the power options using their own switches. Our Medical Director found that the enrollee's condition does not meet criteria for coverage of an expandable controller.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an expandable controller have not been met. Therefore, we decided that the Plan does not have to pre-approve an expandable controller (E2311) for the enrollee.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance transport (A0428, A0425) provided on February 
15, 2023. 
 
You asked the Plan to pay for ambulance transport. You say that ambulance transport was a medical necessity 
for you. The Plan denied your request. The Plan says rules for payment have not been met. 
 The Plan must follow Medicare rules. The rules say that Medicare covers ambulance transports (that meet all 
other program requirements for coverage) only to the destinations listed in the Medicare rules section of this 
letter. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance transport have not been met. Specifically, the record shows that ambulance services 
were provided to transport you to a crisis center. A crisis center is not a Medicare-covered destination for 
ambulance transport. Therefore, we decided that the Plan does not have to pay for ambulance transport (A0428, 
A0425) provided on February 15, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99215 and 72040 provided on January 25, 
2023. 
 
You asked the Plan to pay for procedure codes 99215 and 72040. You say that these services were medically 
necessary. The Plan denied your request. The Plan says coverage criteria has not been met. 
 
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 99215 and 72040 are not supported in the medical record. Specifically, diagnosis 
codes M54.2 (Cervicalgia) and M50.222 (Other cervical disc displacement at C5-C6 level) have an exclude 
note and cannot be reported together. Based on this information, we decided that Medicare rules for coverage 
of procedure codes 99215 and 72040 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure codes 99215 and 72040 provided on January 25, 2023.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychiatric diagnostic evaluations and psychotherapy 
services provided from March 1, 2023, to March 20, 2023. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluations and psychotherapy services. You say that 
no one advised you that the provider is not accepting Medicare. The Plan denied your request. The Plan says 
there is coverage for mental health, but it is not covered when billed by a mental health counselor. 
 
The Plan must follow Medicare rules. Medicare rules say that a Mental Health Counselor is not eligible to 
participate in the Medicare program.  
 
We looked at the file and Medicare rules. The provider at issue in this case is a Mental Health Counselor. 
Medicare says that a Mental Health Counselor is not eligible to participate in the Medicare program. Therefore, 
we decided that the Plan does not have to pay for psychiatric diagnostic evaluations and psychotherapy services 
provided from March 1, 2023, to March 20, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for  the Unity Complete test (81220, 81329, 81403, 81420) 
provided January 14, 2023. 
 You asked the Plan to pay for the laboratory service. You say that you are requesting payment in full for the 
test performed. The Plan denied your request. The Plan says the Unity Complete test requested does not meet 
the requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at this the file, and Medicare rules. The test has not been approved by MolDX and was requested 
solely for screening purposes. Medicare does not cover this test solely for screening purposes. Based on this 
information, we decided that Medicare rules for coverage of the laboratory service have not been met. 
Therefore, we decided that the Plan does not have to pay for the Unity Complete test (81220, 81329, 81403, 
81420) provided January 14, 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 enrollee will clearly benefit from acute 
rehabilitation to optimize their level of functioning prior to returning home. The Plan denied your request. The 
Plan says the IRF services you are requesting do not meet the requirements for approval.  
 
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 complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve office services to be provided by an out-of-network 
(OON) provider.  
 
You asked the Plan to pre-approve office services. You say that your physician wants you to get a second 
opinion outside of the Plan network. The Plan denied your request. The Plan says this provider is out-of-
network with the Plan and you can get a second opinion within the Plan network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
office services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for the facet injection provided on January 20, 
2023. 
 
You asked the Plan to reduce the copayment for the facet injection. You say that you should only have a $100 
copayment. 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 $275 
copayment for in-network outpatient hospital services. 
 
You have been asked to pay a $275 copayment for the facet injection. This item/service falls within the in-
network outpatient hospital 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. Therefore, we decided that the Plan does not have to reduce the copayment for 
the facet injection provided on January 20, 2023.