Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99291 billed for date of service June 14, 
2023. 
 
You asked the Plan to pay for the billed services. You say that the dictation and transcription date are the actual 
date the services were rendered. The Plan denied your request. The Plan says the billed code cannot be verified. 
 
The Plan must follow Medicare rules. Medicare rules say that the provider 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. The file shows that the enrollee received care from June 7-22, 2023. 
The documentation does not clearly show that the medical records provided are for services provided on June 
14, 2023. The transcription date and the dictation date are not sufficient to verify the date as dictation and 
transcription does not necessarily have to occur at the time the services are provided. Based on this 
information, we decided that there is insufficient information in the record to determine if Medicare rules for 
coverage of the billed services have been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99291 billed for date of service June 14, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve prochlorperazine. 
 
You asked the Plan to pre-approve the medication. You say that you are appealing with supporting records. The 
Plan denied your request. The Plan says the medication is not covered as a medical benefit under the Plan. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve prochlorperazine.   
Benefits for the medication may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for the portable imaging transportation services (R0070) provided on 
January 26, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that transportation of 
portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, R0070, 
requires a qualified accompanying radiological procedure be reported on the same date of service by the same 
or different provider. 
 
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 transportation of portable x-ray equipment, with code 
R0070, requires a qualified accompanying radiological procedure be reported on the same date of service. 
However, the documentation submitted by the Plan does not support this argument. Medicare rules say that this 
is true for code R0075, but the rules do not mention this stipulation for code R0070. Without supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
portable imaging transportation services (R0070) provided on January 26, 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 pay for procedure codes 11755, 11056 and 11721 billed for date of 
service June 3, 2023. 
 
You asked the Plan to pay for procedure codes 11755, 11056 and 11721. You say that these services were 
necessary and are supported as billed. The Plan denied your request. The Plan says the service at issue was not 
billed with the required modifier to allow separate payment within the global surgery period. 
 The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM 
services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 28190 
provided on May 27, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure codes 11755, 11056 and 
11721 billed for date of service June 3, 2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code J3490 billed for June 29, 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 service at issue was not billed with the required modifier to allow separate payment 
within the global surgery period. 
 
The Plan must follow Medicare rules. Medicare rules say that many services within the postoperative period 
are considered to be included within payment for the global surgical procedure. Two exceptions to this are EM services unrelated to the surgical procedure, which should be billed with modifier -24, and unrelated surgical 
procedures, which should be billed with modifier -79.  
 
We looked at the file and Medicare rules. The service at issue is within the global surgery period of code 64493 
provided on June 29, 2023. We find that the service at issue may be unrelated to the surgical procedure; 
however, the required modifier to indicate this was not used. As such, the billing rules for these services have 
not been met. Therefore, we decided that the Plan does not have to pay for procedure code J3490 billed for 
June 29, 2023.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory panel provided on March 1, 2023, billed with 
codes 87640, 87500, 87481, 87798 and 87652. 
 
You asked the Plan to pay for the laboratory panel billed. You say that this testing was necessary and is 
supported in the medical record. 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 a 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 a laboratory 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 laboratory 
panel billed have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory 
panel provided on March 1, 2023, billed with codes 87640, 87500, 87481, 87798 and 87652.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel rendered on 
May 23, 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 services were not billed as a single unit of service. 
 
The Plan must follow Medicare rules. The rules say that a urine PCR panel cannot be unbundled and billed as 
individual components. 
 
We looked at the file and Medicare rules. The file shows that the urine PCR panel was not billed as a single 
unit of service. 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 the urine polymerase chain reaction 
(PCR) panel rendered on May 23, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a minimally invasive lumbar decompression. 
 
You asked the Plan to pre-approve a minimally invasive lumbar decompression. You say that the enrollee has 
complaints of lower back pain. The Plan denied your request. The Plan says this procedure has been correctly 
denied. 
 
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 minimally invasive lumbar 
decompression. Our reviewer says that the requested items/services are not considered medically reasonable 
and necessary in this case. Our physician reviewer found this procedure is considered experimental. 
 
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 minimally invasive lumbar decompression have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a minimally invasive lumbar decompression.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services provided on January 19, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim must be 
submitted to the primary insurer. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer. 
 
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the 
provider to send the bill to the primary insurer. As the secondary insurer, the Plan cannot be held responsible 
for the services until the primary insurer has denied the claim for these services. Therefore, we decided that the 
Plan does not have to pay for the services provided on January 19, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power scooter. 
 
You asked the Plan to pre-approve a power scooter. You say that a motorized scooter would allow the enrollee 
to maintain some mobility independence. You say that a walker and manual wheelchair require use of both 
arms, which the enrollee cannot do. You also say this is medically necessary for the enrollee. The Plan denied 
your request. The Plan says the records do not support that the enrollee can safely operate the requested power 
scooter. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patients condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 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 power scooter. Our reviewer says that 
the coverage criteria have not been met. Our physician reviewer found the record does not support the enrollee 
requires a scooter to manage self-care in the home or that the home can accommodate a scooter. Therefore, the 
reviewer found that the requested power scooter is not medically reasonable or 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 a power scooter have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a power scooter.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on April 11, 2023, billed with 
codes 81225, 81227, 81230, 81231, 81232, 81241, 81240, 81306, 81328, 81335, and 81401. 
 
You asked the Plan to pay for the genetic testing billed. You say that you disagree with the denial. 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 
April 11, 2023, billed with codes 81225, 81227, 81230, 81231, 81232, 81241, 81240, 81306, 81328, 81335, 
and 81401.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF care provided from April 7, 2023, to May 6, 2023. 
 
 You asked the Plan to pay for SNF care. You say that the services provided by the SNF were necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee no longer required a SNF level of care 
during the time in question. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is 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 pay for SNF care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy 
needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF setting. The 
enrollee's care needs could have been provided in a lower 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pay for SNF care provided from April 7, 2023, to May 6, 2023.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve suction assisted lipectomy of the trunk. 
 
You asked the Plan to pre-approve lipectomy. You say that the enrollee would benefit from this surgery. The 
Plan denied your request. The Plan says this procedure is considered cosmetic. 
 
The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not 
covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are 
coverable.   
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve lipectomy. Our reviewer says that this 
surgery is not medically necessary. Our reviewer found the record provided does not document the presence of 
chronic interigo refractory to conservative medical treatment or functional impairment.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of lipectomy have not been met. Therefore, we decided that the Plan does not have 
to pre-approve suction assisted lipectomy of the trunk.
Appeal type: ER
Decision: Favorable

 
We decided that the Plan has to pay for the emergency care you received on June 22, 2023. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the claim is not 
payable for the billed diagnosis. 
 
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. 
 
You were provided the services by a contract provider. The file does not show that the Plan provided notice 
that the services would not be covered. Under Medicare rules, this means the services is considered approved 
by the Plan. Therefore, we decided that the Plan has to pay for the emergency care you received on June 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 pre-approve permanent cardiac contractility modulation system.  
 
You asked the Plan to pre-approve permanent cardiac contractility modulation system. You say that permanent 
cardiac contractility modulation system is medically necessary. The Plan denied your request. The Plan says 
permanent cardiac contractility modulation system is experimental/investigational. 
 
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 permanent cardiac contractility 
modulation system. Our reviewer says that the requested permanent cardiac contractility modulation system is 
not considered medically reasonable and necessary. Our physician reviewer found cardiac contractility 
modulation device still remains in an experimental phase without a proven meaningful benefit in any large 
Randomized Clinical Trails (RCT) and yet to be endorsed and recommended by any professional societies' guidelines for advanced heart failure 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 permanent cardiac contractility modulation system have not been met. 
Therefore, we decided that the Plan does not have to pre-approve permanent cardiac contractility modulation 
system.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency 
transport, and ground mileage provided on December 12, 2022, to March 3, 2023. 
 
You asked the Plan to pay for the ambulance services ground mileage. You say that the submitted 
documentation supports the need for the ambulance transport. You also say that service code A0428 seems 
appropriate based on the enrollee's condition. The Plan denied your request. The Plan says the ambulance 
services were not medically necessary. 
 
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan 
follows the same rules.  
 
 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 the ambulance services ground mileage. Our 
reviewer says that the ambulance services were not medically necessary. Our physician reviewer found the 
documentation does not support that other means of transport (such as stretcher van, wheelchair van, taxi, 
private car, or other type of vehicle) were contraindicated for the enrollee. The documentation does not support 
that the enrollee needed the expertise, services and lifesaving and life-sustaining equipment that only a fully 
equipped ambulance can provide for a safe transport. The documentation also does not support that the 
ambulance transport was medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ambulance services ground mileage have not been met. Therefore, we 
decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport, 
and ground mileage provided on December 12, 2022, to March 3, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics and attendant control. 
 
You asked the Plan to pre-approve the upgraded electronics and attendant control. You say that this is 
medically necessary for the enrollee. The Plan denied your request. The Plan says the notes do not show a 
medical need to control the power options through a joystick. The Plan also says an attendant control cannot be 
covered if a user-operated control is requested. 
 
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 upgraded electronics and attendant 
control. Our reviewer says that the requested upgraded electronics are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the provided documentation indicates the enrollee has 
sufficient strength and function in upper extremities to manage standard power drives. Therefore, the reviewer 
found that the request for upgraded electronics is not medically reasonable or necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the upgraded electronics and attendant control have not been met. Therefore, we 
decided that the Plan does not have to pre-approve the upgraded electronics and attendant control.