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

 
We decided that the Plan does not have to pre-approve proton beam therapy (77522, 77523, 77525). 
 
You asked the Plan to pre-approve proton beam therapy. You say that you are requesting reconsideration 
because proton therapy is reasonable and necessary to treat prostate cancer in this case and with standard 
radiation treatment, there are serious side effects. The Plan denied your request. The Plan says the requested 
treatment 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 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 proton beam therapy. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there is no clear evidence that proton beam therapy for prostate cancer offers any 
clinical advantage over other forms of definitive radiation therapy. Clinical trials are necessary to establish a 
possible advantage of this expensive therapy. The bottom line is that proton therapy for prostate cancer is not 
experimental, and in fact is an accepted treatment approach. To date, there is no compelling data to suggest that 
proton therapy is superior to or more beneficial than IMRT/IGRT. The generally accepted standard of care for 
prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to enrollees. 
While NCCN guideline consider proton therapy a reasonable alternative they do not describe it as being 
necessary in lieu of non-proton-based treatment and are quite explicit in that there is no evidence of its 
superiority. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of proton beam therapy have not been met. Therefore, we decided that the Plan 
does not have to pre-approve proton beam therapy (77522, 77523, 77525).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the additional 3 units of code 99292 billed for date of service 
May 10, 2022. 
 
You asked the Plan to pay for the additional 3 units of code 99292. You say that you feel that these additional 
units should be reimbursed. The Plan denied your request. The Plan says the additional units 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 99292 is critical care, evaluation and management of the 
critically ill or critically injured patient; each additional 30 minutes (List separately in addition to code for 
primary service). 
 
 We find that the additional 3 units of CPT code 99292 is not supported in the medical record. Specifically, the 
time documented in the progress notes for this date of service do not account for the additional 90 minutes of 
critical care beyond the 5 hours of care time that were already reimbursed. Based on this information, we 
decided that Medicare rules for coverage of the additional 3 units of code 99292 have not been met. Therefore, 
we decided that the Plan does not have to pay for the additional 3 units of code 99292 billed for date of service 
May 10, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for laboratory services (87150, 87798, 87640, 87799, 87653 and 87482) 
provided on June 1, 2022. 
 
You asked the Plan to pay for laboratory services. You say that this testing was medically necessary and is 
supported in the medical record. The Plan denied your request. The Plan says that an infectious disease panel 
should be billed with only one 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 not cited the rule used to make their decision and we 
were unable to find this information in a determination which applies to the state where these services were 
provided. In addition, the services at issue were each 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 (87150, 87798, 87640, 87799, 
87653 and 87482) provided on June 1, 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: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code G0483. We decided that the Plan does not have to pay 
for procedure code 84480.  You asked the Plan to pay for procedure codes G0483 and 84480 billed for date of service May 12, 2022. You 
say that these services were reported correctly. The Plan says that the medical records do not support the use of 
code G0483 as only 14 drug classes were tested in this case. In addition, the payment for code 84480 is 
included in the payment for code 84481. 
 
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 decided that the Plan has to pay for procedure code G0483.  
 
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 supported in the medical record. Specifically, the medical records support that 
drugs from at least 22 drug classes were tested in this case. Based on this information, we decided that 
Medicare rules for coverage of code G0483 have been met. Therefore, we decided that the Plan has to pay for 
procedure code G0483.  
 
We also decided that the Plan does not have to pay for procedure code 84480. 
 
In this case, we have confirmed that code 84480 is a column II code to column I code 84481 with a modifier 
indicator of 0. The column II code is therefore not payable, even if a modifier is used. Based on the claim 
submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code 84480. 
 
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 procedure code 99284 provided on October 30, 2022. 
 
You asked the Plan to pay for procedure code 99284. You say that the medical records support the billing of 
code 99284. The Plan denied your request. The Plan says the medical records do not support the billing of code 
99284. 
 
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 99284 is Emergency department visit for the evaluation 
and management of a patient, which requires these 3 key components: A detailed history; A detailed 
examination; and medical decision making of moderate complexity. Counseling and/or coordination of care 
with other physicians, other qualified health care professionals, or agencies are provided consistent with the 
nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician, or other qualified health care professionals but do not 
pose an immediate significant threat to life or physiologic function. 
 
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 procedure code 99284. Our reviewer says that the medical 
records do not support the billing of code 99284. Our reviewer found the medical notes describe the enrollee 
status post knee replacement with urinary retention. The histories were focused and brief and the physical 
examination brief and focused as well. The enrollee was treated with Foley without complication. The code, 
99284, was submitted. However, the provided notes did not show evidence of a detailed history or physical for 
this date, nor was there evidence of medical decision-making in the provided notes. The enrollee was stable. 
Therefore, the code, 99284 is not sufficiently supported in the provided documentation. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 99284 have not been met. Therefore, we decided that the Plan 
does not have to pay for procedure code 99284 provided on October 30, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for Guardant360 CDx (81479) provided on November 16, 2021. 
 
You asked the Plan to pay for Guardant360 CDx. You say that this test was medically necessary and was 
reported appropriately. The Plan denied your request. The Plan says that the claim for this molecular pathology 
testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. This test is listed in the DEX database as covered. This determination 
was made and is specific to the test at issue. Review of the claim shows that the required unique identifier was 
reported. Based on this information, we decided that Medicare rules for coverage of Guardant360 CDx have 
been met. Therefore, we decided that the Plan has to pay for Guardant360 CDx (81479) provided on November 
16, 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: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the Prospera kidney transplant assessment provided on May 13, 2022. 
 
You asked the Plan to pay for the Prospera testing. You say that this testing was deemed medically necessary 
by the treating physician and is covered by Medicare. The Plan denied your request. The Plan says that records 
from the in-network ordering physician were not submitted. As such, medical necessity cannot be determined. 
 
Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract 
provider are considered approved by the plan unless notice is provided that the services will not be covered. 
The plan follows these rules. 
 
The enrollee was referred for the Prospera testing by a contract provider. We verified that the DEX Diagnostics 
Exchange lists this test as covered by Medicare. The file does not show that the plan provided notice that the 
Prospera testing would not be covered. Under Medicare rules, this means the Prospera testing is considered 
approved by the plan. Therefore, we decided that the Plan has to pay for the Prospera kidney transplant 
assessment provided on May 13, 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: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for emergency room services (99285) provided on December 30, 
2021. 
 
You asked the Plan to pay for the emergency room services. You say that this service was 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. 
 
In this case, the CPT Code Manual definition of code 99285 is an Emergency Department Visit, with a 
comprehensive history and physical, and medical decision making of a high complexity. 
 
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 emergency room services. Our reviewer says that this 
service is not supported by the records. Our reviewer found there was no high complexity medical decision making noted in the records. 
 
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 emergency room services have not been met. Therefore, we decided that the 
Plan does not have to pay for emergency room services (99285) provided on December 30, 2021.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 93005 and 96360 for date of service 
November 12, 2022. 
 
You asked the Plan to pay for procedure codes 93005 and 96360. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable as 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 code 93005 is electrocardiogram, routine ECG with at least 12 
leads; tracing only, without interpretation and report.  
The CPT Code Manual definition of code 96360 is intravenous infusion, hydration; initial, 31 minutes to 1 
hour. 
 
Procedure code 93005 has a status indicator of Q1. Code 99285 was also billed on the same date of service 
with a revenue code of 450 which has a status indicator of "V". Therefore, code 93005 is not separately payable 
as billed. 
 
Procedure code 96360 was billed with diagnosis codes B34.9 and R53.1. These diagnosis codes are not listed 
as ones that are medically necessary for code 96360 to be supported. 
 
We find that CPT codes 93005 and 96360 are not supported in the medical record. Specifically, code 93005 is 
not separately payable as billed. Code 96360 was billed with diagnosis codes that do not support medical 
necessity of this procedure. Based on this information, we decided that Medicare rules for coverage of 
procedure codes 93005 and 96360 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 93005 and 96360 for date of service November 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve repeat radiofrequency ablation (RFA) procedures 
(64635, 64636). 
 
You asked the Plan to pre-approve repeat RFA. You say that the requested services are is a medical necessity 
for the enrollee. The Plan denied your request. The Plan says the requested services are not medically 
necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve repeat RFA. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the provided records indicate that the enrollee has undergone previous applications of this treatment. The 
last set of procedures resulted in 30% relief for one month. However, the criteria for a successful block 
mandate 50% pain relief for 6 months.  
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of repeat RFA have not been met. Therefore, we decided that the Plan does not 
have to pre-approve repeat radiofrequency ablation (RFA) procedures (64635, 64636).
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the psychotherapy, 60 minutes, (90837) provided on December 22, 
2022. 
 
You asked the Plan to pay for the psychotherapy service. You say that you were originally scheduled to see a 
different provider. You say that you did know until the day of that you were seeing someone else. You say that 
the provider you were scheduled to see was not able to be there that day. You also say that you were not told 
this provider was not contracted with your plan. The Plan denied your request. The Plan says that the provider 
in this case is not eligible for Medicare payment. 
 
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 did not address the fact that you were supposed to see a 
psychiatrist, but the provider was unable to be there that day and the office sent you to the provider that 
rendered services in this case. Therefore, we decided that the Plan has to pay for the psychotherapy, 60 
minutes, (90837) provided on December 22, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on November 16, 2022. 
 You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the claim was not billed 
with the appropriate DEX Z-code. 
 
The Plan must follow Medicare rules. Medicare rules say that to report a Molecular Diagnostic Test service, the 
appropriate claim information must be submitted.  
 
We looked at the file and Medicare rules. In this case, the claim was submitted without an appropriate DEX Z-
Code as required by LCA A57526. Based on this information, we decided that Medicare rules for coverage of 
the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing 
provided on November 16, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services (G0483, 80307) provided on October 
17, 2022. 
 You asked the Plan to pay for drug testing. You say that these services were medically necessary and are 
supported as billed. The Plan denied your request. The Plan says there is insufficient documentation to support 
these services as medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as 
appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is 
due and the amount of payment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that there is insufficient 
information in the record to determine if Medicare rules for coverage of drug testing have been met. 
Specifically, no physician order for these services was included in the medical record, and the physician notes 
do not indicate an intent for these tests to be performed. Therefore, we decided that the Plan does not have to 
pay for drug testing services (G0483, 80307) provided on October 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377) with related electronic 
connections (E2311) and harness (E2313) for use with an approved power wheelchair. 
 
You asked the Plan to pre-approve the expandable controller and related hardware. You say that it is felt that 
all requested components are required. The Plan denied your request. The Plan says the expandable controller 
is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the expandable controller and related 
hardware. Our reviewer says that the requested items are not considered medically reasonable and necessary in 
this case. Our physician reviewer found the enrollee has adequate strength in her upper extremity to manage 
multiple standard power drive switches. The expandable controller exceeds the enrollee's medical need.  
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 expandable controller and related hardware have not been met. Therefore, 
we decided that the Plan does not have to pre-approve an expandable controller (E2377) with related electronic 
connections (E2311) and harness (E2313) for use with an approved power wheelchair.