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

 
We decided that the Plan does not have to pay for a swallowing function, with 
cineradiography/videoradiography (Video Fluoroscopy), a cervical spine X-ray single view, diagnostic 
radiology procedures of the head and neck and radiologic examination, teeth provided on December 19, 2022. 
 
You asked the Plan to pay for a swallowing function, with cineradiography/videoradiography 
(Video Fluoroscopy), a cervical spine X-ray single view, diagnostic radiology procedures of the head and neck 
and radiologic examination, teeth. 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 a swallowing function, with cineradiography/videoradiography (Video Fluoroscopy), a cervical 
spine X-ray single view, diagnostic radiology procedures of the head and neck and radiologic examination, 
teeth have not been met. Therefore, we decided that the Plan does not have to pay for a swallowing function, 
with cineradiography/videoradiography (Video Fluoroscopy), a cervical spine X-ray single view, diagnostic 
radiology procedures of the head and neck and radiologic examination, teeth provided on December 19, 2022.
Appeal type: Lab
Decision: Favorable

 
We decided that the Plan has to pay for the drug testing services provided on November 22, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that code G0482 is not 
payable because code G0480 was already paid for this date of service. 
 
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. The Plan argues that code G0482 is not payable because code G0480 was 
already paid for this date of service. However, the Plan has not provided documentation showing that code 
G0480 was billed and paid for the date of service in question. Without supporting documentation, the Plan's 
denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the drug testing services 
provided on November 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for supplies (A7030, A7031, A7035, A7038) for a positive 
airway pressure (PAP) device provided on March 31, 2023. 
 
You asked the Plan to pay for PAP supplies. You say that you have reported the items at issue correctly. The 
Plan denied your request. The Plan says rules for payment for the items at issue have not been met. 
 
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 PAP supplies have been met. 
Specifically, no medical records have been provided to support the medical necessity of the items at issue. 
Therefore, we decided that the Plan does not have to pay for supplies (A7030, A7031, A7035, A7038) for a 
positive airway pressure (PAP) device provided on March 31, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to ESRD provided on March 
9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you have billed the services 
at issue correctly. The Plan denied your request. The Plan says Medicare does not separately pay for ESRD-
related laboratory testing. 
 
  The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to ESRD provided on March 9, 2022.
Appeal type: Surgery
Decision: Favorable

 
We decided that the Plan has to pre-approve the SpaceOAR procedure (55874, 55876, 77332, 76942). 
 
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan 
denied your request. The Plan says that SpaceOAR is not proven safe/effective for management of high risk 
prostate cancer. SpaceOAR placement is not supported by high quality clinical outcomes reported in the peer 
reviewed medical literature for patients with high risk disease.  
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 services. Our reviewer says that the 
requested items/services are considered medically reasonable and necessary in this case. Our physician 
reviewer found the hydrogel spacer can be considered medically necessary when justified (even for patients 
with high or unfavorable intermediate risk disease, acknowledging that the level 1 data did not include these 
patients). It would be within accepted standards of care to do so. 
 
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 services have been met. Therefore, we decided that the Plan has to pre-
approve the SpaceOAR procedure (55874, 55876, 77332, 76942).  
 
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: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for a chest x-ray provided on July 3, 2022. 
 
You asked the Plan to pay for the chest x-ray. The Plan denied your request. The Plan says that IPA/PHO has 
financial responsibility. 
 
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 provided a Medicare rule, a Plan rule or a coding 
rule to substantiate their denial. Therefore, we decided that the Plan has to pay for a chest x-ray provided on 
July 3, 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: Favorable

 
We decided that the Plan has to pay for laboratory services (86334, 83521, 84165, 82784, 83615) provided on 
October 7, 2022. 
 
You asked the Plan to pay for laboratory services. You say that these services were medically necessary and 
were reported correctly. The Plan denied your request. The Plan says that this claim is missing or has invalid 
HCPCS/CPT codes. 
 
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 five CPT codes reported on this claim are valid codes. The Plan 
does not provide any other information in their argument to clarify which code is supposedly missing or invalid 
on this claim. We are unable to verify the accuracy of the Plan's denial in this case. Therefore, we decided that 
the Plan has to pay for laboratory services (86334, 83521, 84165, 82784, 83615) provided on October 7, 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 wound care services provided on March 02, 2023. 
 
You asked the Plan to pay for wound care services. You say that this service is supported in the records. 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 wound care services 
provided on March 02, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code(s) 73521-TC, R0070 and Q0092 billed for 
date of service November 16, 2022. 
 
You asked the Plan to pay for procedure code(s) 73521-TC, R0070 and Q0092. You say that the claim is billed 
correctly and should be paid. The Plan denied your request. The Plan says this code is included in the facility 
payment and is not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that this service was provided to the enrollee while an inpatient or outpatient. In this case, 
an appropriate modifier to indicate the professional component has not been billed with CPT code(s) 73521-
TC, R0070 and Q0092. Based on this information, we decided that Medicare rules for coverage of procedure 
code 73521-TC, R0070 and Q0092 have not been met. Therefore, we decided that the Plan does not have to 
pay for procedure code(s) 73521-TC, R0070 and Q0092 billed for date of service November 16, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an out-of-network orthopedic referral. 
 
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your 
request. The Plan says the enrollee has no continuity of care with this out-of-network provider. 
 
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 
an out-of-network orthopedic referral.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesiology services provided on September 28, 2022. 
 
You asked the Plan to pay for anesthesiology services. You say that this was medically necessary and should be 
covered. 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 anesthesiology services 
provided on September 28, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health physical therapy  (G0299). 
 You asked the Plan to pre-approve home health services. You say that the services are medically necessary. 
The Plan denied your request. The Plan says the services are 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 pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found the records do 
not show that skilled therapy services are required to effectively provide treatment, care, and/or services in 
order to improve your level of function, or to establish/perform a maintenance program to maintain your level 
of function and/or prevent deterioration. You have had extensive prior therapy and your functional level does 
not require ongoing formal skilled therapy. You have had instruction on safety and a home exercise plan and do 
not require ongoing skills of a professional therapist for your condition. 
 
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 pre-approve home health physical therapy  (G0299).
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure code 80307. We decided that the Plan does not have to pay 
for procedure code G0482.   
You asked the Plan to pay for procedure codes G0482 and 80307 billed for March 22, 2023. You say that you 
disagree with the denial. The Plan says that the services are not supported. 
 
We decided that the Plan has to pay for procedure code 80307. 
 
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. The Plan has not provided clear explanation as to why code 80307 is not 
covered. There is no documentation or binding Medicare rules to support a denial. Therefore, we decided that 
the Plan has to pay for procedure code 80307 billed for March 22, 2023. 
 
We also decided that the Plan does not have to pay for procedure code G0482. 
 
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 G0482 is definitive drug testing, 15-21 drug classes. 
 
We find that CPT code G0482 is not supported in the medical record. Specifically, the file shows that only 14 
drug classes were tested. Based on this information, we decided that Medicare rules for coverage of these 
services have not been met. Therefore, we decided that the Plan does not have to pay for procedure code G0482 
billed for March 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment for an in-network esophagus procedure 
provided on February 09, 2023. 
 
You asked the Plan to waive the copayment for an in-network esophagus procedure. You say that this 
copayment is too big, you should only have to pay $30. 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 $150 
copayment for outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical center.  
You have been asked to pay a $150 copayment for an in-network esophagus procedure. This item/service falls 
within the outpatient surgery and other medical services provided at hospital outpatient facilities and 
ambulatory surgical center 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 an in-
network esophagus procedure provided on February 09, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the knee x-rays provided on March 01, 2023. 
 
You asked the Plan to pay for the knee x-rays. You say that the services provided should be covered. 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 knee x-rays provided 
on March 01, 2023.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home health services. 
 You asked the Plan to pre-approve home health services. You say that this is medically necessary. The Plan 
denied your request. The Plan says the services are 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 pre-approve home health services. Our reviewer 
says that the services are not medically reasonable and necessary. Our physician reviewer found that the 
records do not show that skilled nursing services are required to effectively provide treatment, care, and/or 
services in order to improve the enrollee's condition, or to establish/perform a maintenance program to 
maintain the enrollee's condition and/or prevent deterioration. The enrollee has had extensive prior skilled 
nursing and has had instruction on medication, disease, and safety. There is no evidence of a physician 
signature on a care plan. There is no evidence of complex wound care or other skilled nursing need. The 
request for ongoing skilled nursing is 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 home health services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve home health services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the molecular pathology services provided on December 06, 
2022. 
 
You asked the Plan to pay for the molecular pathology services. 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 the molecular pathology 
services provided on December 06, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for Practitioner services provided on January 19, 2023, billed 
with codes 99291 and 99292. 
 
You asked the Plan to pay for the Practitioner services provided. You say that the claim is billed correctly and 
should be paid. The Plan denied your request. The Plan says the claim was billed with an invalid diagnosis. 
 
The Plan must follow Medicare rules. Medicare rules say that an Excludes1 note indicates that the code 
excluded should never be used at the same time as the code above the Excludes1 note. 
  
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Practitioner services provided have not been met. This claim was billed with diagnosis codes 
R06.00 and J96.01 which is a code pair that is subject to an Excludes1 note and should not be reported together. Therefore, we decided that the Plan does not have to pay for Practitioner services provided on January 
19, 2023, billed with codes 99291 and 99292.