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

 
We decided that the Plan does not have to pay for the genetic testing provided on December 7, 2022, billed 
with codes 81226, 81240, 81241, 81306, and 81335. 
 
You asked the Plan to pay for the genetic testing billed. You say that the was medically necessary. The Plan 
denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
December 7, 2022, billed with codes 81226, 81240, 81241, 81306, and 81335.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 99291, 76937 and 36556 for date of service 
January 7, 2023. 
 
You asked the Plan to pay for procedure codes 99291, 76937 and 36556. 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. 
 
We find that CPT code 99291, 76937 and 36556 is not supported in the medical record. Specifically, the 
documentation submitted did not support a critical care visit of 30-74 minutes was performed on the 
billed date of service. The documentation does not include the time spent providing this service; therefore, code 
99291 is not supported. The documentation submitted didn't include a detailed procedure note for ultrasound 
guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of 
selected vessel patency, concurrent real time ultrasound visualization of vascular needle entry, with permanent recording and reporting on the billed date of service; therefore, code 76937 cannot be verified. The 
documentation submitted did not include a detailed procedure note for insertion of non-tunneled centrally 
inserted central venous catheter; age 5 years or older on the billed date of service; therefore, code 36556 cannot 
be verified. 
 
Based on this information, we decided that Medicare rules for coverage of procedure codes 99291, 76937 and 
36556 have not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 99291, 
76937 and 36556 for date of service January 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from April 12, 2023, to 
April 25, 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 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 April 12, 2023. The NOA was not received by the Plan. 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 the home health services rendered from April 12, 
2023, to April 25, 2023.
Appeal type: Practitioner Services
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services described by procedure code(s) 36558-RT, 77001-26, and 
99152. We decided that the Plan does not have to pay for the services described by procedure code(s) 99153.  
 
You asked the Plan to pay for practitioner services provided on April 3, 2023, billed with procedure codes 
99153, 36558-RT, 99152 and 77001-26. You say that the claim is billed correctly and should be paid. The Plan 
says that code 99153 is not payable in the facility setting.  
 
We decided that the Plan has to pay for the services described by procedure code(s) 36558-RT, 77001-26, 
and 99152.  
 
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 make an appeal decision for the codes listed in this 
section. The Plan is not allowed to reopen any determinations while an appeal is pending and must issue a 
determination on all appealed services within the appeal time frame. As the Plan forfeited its opportunity to 
provide a denial rationale for these services, we find that the denial of payment is not supported. Therefore, we 
decided that the Plan has to pay for the services described by procedure code(s) 36558-RT, 77001-26, and 
99152.  
 
We also decided that the Plan does not have to pay for the services described by procedure code(s) 
99153. 
 
The Plan follows Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a PE 
only code and that PE are not payable to the physician for services provided in the facility setting.  
 
We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the services described by procedure code(s) 99153 have not been met. There is no separate 
payment to the physician for CPT code 99153 when performed in the facility setting. Therefore, we decided 
that the Plan does not have to pay for the services described by procedure code(s) 99153. 
 
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 pay for procedure code 29540 billed for date of service February 8, 
2023.  
 You asked the Plan to pay for procedure code 29540. 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 29540 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 29540 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 29540 billed for date of service February 8, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for the diagnostic hearing exam provided on 
March 03, 2023. 
 
You asked the Plan to waive the copayment for the diagnostic hearing exam. You say that this occurred during 
an office visit. 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 $15 
copayment for hearing services. 
 
You have been asked to pay a $15 copayment for the diagnostic hearing exam. This item/service falls within 
the hearing 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 waive the copayment for the diagnostic 
hearing exam provided on March 03, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
January 13, 2023.  
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service January 13, 2023.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Euflexxa. 
 You asked the Plan to pre-approve Euflexxa. You say that Euflexxa is medically necessary. The Plan denied 
your request. The Plan says a trial of Orthovisc or Supartz FX is required before alternatives can be considered. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 Euflexxa. Our reviewer says that 
Euflexxa is not medically necessary. Our physician reviewer found the records show no trial of the plan 
preferred drugs, or any reason they would be unsafe or ineffective. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Euflexxa have not been met. Therefore, we decided that the Plan does not have 
to pre-approve Euflexxa.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy service provided on April 5, 2023, by an 
OON provider.   
You asked the Plan to pay for the physical therapy service. You say that the provider is appealing the denial. 
The Plan denied your request. The Plan says the service was not authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the physical therapy service provided on April 5, 
2023, by an OON provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental 
pneumatic appliance (E0673) provided on February 9, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that this device was provided for use 
during the patient's surgery. The Plan denied your request. The Plan says equipment used in a facility for a 
procedure is not separately payable. 
 
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate 
and needed for use inside the home.  
 
The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither 
Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device (E0675) and segmental pneumatic appliance (E0673) 
provided on February 9, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services for date of service November 14, 
2022, to November 30, 2022. 
 You asked the Plan to pay for the home health services. You say that you disagree with the Plan's denial. 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 November 14, 2022. The NOA was not received by the Plan until January 
27, 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 the home health services for 
date of service November 14, 2022, to November 30, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Motion fluoroscopic evaluation of swallowing function by 
cine or video recording, Radiologic examination, swallowing function, with cineradiography/video 
radiography, Radiologic examination, spine, cervical; 2 or 3 views, Radiologic examination, mandible; partial, 
less than 4 views, Radiologic examination, teeth; partial examination, less than full mouth and Radiologic 
examination, upper gastrointestinal tract provided on February 7, 2023. 
 
You asked the Plan to pay for Motion fluoroscopic evaluation of swallowing function by cine or video 
recording, Radiologic examination, swallowing function, with cineradiography/video radiography, Radiologic 
examination, spine, cervical; 2 or 3 views, Radiologic examination, mandible; partial, less than 4 views, 
Radiologic examination, teeth; partial examination, less than full mouth and Radiologic examination, upper 
gastrointestinal tract. You say that the services were medically necessary. The Plan denied your request. The 
Plan says the services were performed at a nursing home (via mobile van/portable x-ray), which are denied as 
an excluded place of service. 
 
The Plan must follow Medicare rules.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Motion fluoroscopic evaluation of swallowing function by cine or video recording, Radiologic 
examination, swallowing function, with cineradiography/video radiography, Radiologic examination, spine, 
cervical; 2 or 3 views, Radiologic examination, mandible; partial, less than 4 views, Radiologic examination, 
teeth; partial examination, less than full mouth and Radiologic examination, upper gastrointestinal tract have 
not been met. Therefore, we decided that the Plan does not have to pay for Motion fluoroscopic evaluation of 
swallowing function by cine or video recording, Radiologic examination, swallowing function, with 
cineradiography/video radiography, Radiologic examination, spine, cervical; 2 or 3 views, Radiologic 
examination, mandible; partial, less than 4 views, Radiologic examination, teeth; partial examination, less than 
full mouth and Radiologic examination, upper gastrointestinal tract provided on February 7, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from March 6, 2023, to 
March 10, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that home health services must be submitted with the correct 
type of bill. 
 
We reviewed the file and the Medicare rules. We find that the type of bill on the claim is incorrect as billed. 
Based on this information, we find that the Medicare rules for payment of the claim at issue have not been met. 
Therefore, we decided that the Plan does not have to pay for the home health services provided from March 6, 
2023, to March 10, 2023.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, conventional air services, transport, one 
way and air mileage provided on July 6, 2022. 
 
You asked the Plan to pay for the ambulance air services and air mileage. You say that based on clinical 
documentation and a registered nurse who has multiple years of critical care field experience, believes this 
transport meets medical necessity guidelines.  The Plan denied your request. The Plan says the air ambulance 
transport does not meet Medicare guidelines. 
 
 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 the ambulance air services and air 
mileage have been met. Specifically, the medical records supplied were incomplete to support the service 
provided. Without the emergency room medical records we are unable to determine whether the criteria for 
coverage have been met and whether payment is due. Therefore, we decided that the Plan does not have to pay 
for ambulance service, conventional air services, transport, one way and air mileage provided on July 6, 2022.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for each emergency room visit provided on 
February 19, 2023, to February 20, 2023. 
 
You asked the Plan to waive the copayment for each emergency room visit. You say that it was in the 
enrollees best interest not to stay over night. 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 $110 
copayment for emergency care. 
 
You have been asked to pay a $110 copayment for each emergency room visit. This item/service falls within 
the emergency care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled 
in the Plan. The total amount you owe is $220 ($110 copayment x 2 visits = $220). Therefore, we decided that 
the Plan does not have to waive the copayment for each emergency room visit provided on February 19, 2023, 
to February 20, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes B4197, B4185, and B4224 for date of service 
December 1, 2022, to December 31, 2022. 
 
You asked the Plan to pay for codes B4197, B4185, and B4224. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the number of units billed cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report the actual number of units 
provided for each procedure code. 
 
We find that 22 units of code B4197, 88 units of code B4185, and 22 units of code B4224 are not supported in 
the medical record. Review of the file shows that the submitted medical records do not support the units billed. 
The amendment of units/quantity are not attested or verified by the provider. Based on this information, we decided that Medicare rules for coverage of codes B4197, B4185, and B4224 
have not been met. Therefore, we decided that the Plan does not have to pay for codes B4197, B4185, and 
B4224 for date of service December 1, 2022, to December 31, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS HF System.  
 
You asked the Plan to pre-approve the CardioMEMS HF System. You say that the CardioMEMS HF System is 
medically necessary. The Plan denied your request. The Plan says the requested CardioMEMS HF System is 
experimental, investigational and unproven.  
 
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 CardioMEMS HF System. Our 
reviewer says that the requested CardioMEMS HF System is not considered medically reasonable and 
necessary. Our physician reviewer found that the CardioMEMS device was approved by the U.S. Food and 
Drug Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow 
measurement of pulmonary artery pressure in the management of patients with CHF. The clinical study on which the FDA approval was based showed improved clinical outcomes and decreased hospitalizations in 
patients in whom the CardioMEMS system was implanted, reflecting a patient population with preserved 
ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain encouraging and 
suggest an improvement in heart failure symptoms with the use of the device. In addition, published expert 
opinion in the cardiology literature is supportive of the clinical usefulness of CardioMEMS. Nonetheless, 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 the CardioMEMS HF System have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS HF System.