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

 
We decided that the Plan does not have to pay for the services (CPT code A4550, A4649 X2, S1015, and 
S8301) provided on August 19, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered 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. 
 
 Our records indicate that procedure A4550, which has a status indicator of 'B' on the CMS Physician Relative 
Value File, is always bundled into payment for other services not specified and no separate payment is made 
per Medicare. Our records indicate that procedure A4649, which has a status indicator of 'P' on the CMS 
Physician Relative Value File, is always bundled into payment for other services not specified and no separate 
payment is made per Medicare. Medicare guidance says code HCPCS code(s) S1015 and S8301 are assigned a 
status code = I, which is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay 
for the services (CPT code A4550, A4649 X2, S1015, and S8301) provided on August 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing (CPT code 81455) provided on December 
10, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records.  
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 the genetic testing have not been met. The genetic testing was not 
ordered/approved by the ordering provider as per the outreach response. The provider did not write an order for 
Genetic Testing for the enrollee. Therefore, we decided that the Plan does not have to pay for the genetic 
testing (CPT code 81455) provided on December 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a sacroiliac joint injection (27096) for the enrollee. 
 
You asked the Plan to pre-approve these services. You say that the member is in pain and needs the injections. 
The Plan denied your request. The Plan says that records show the enrollee does not have pain with specific 
tests for the sacroiliac joint. 
 
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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. There is no 
documentation of 3 provocative physical exam tests. Our physician reviewer found that the enrollee's condition 
does not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a sacroiliac joint injection (27096) for the enrollee.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ultrasonic guidance for needle placement (76942) provided 
on July 27, 2021. 
 
You asked the Plan to pay for ultrasonic guidance for needle placement. You say that the enrollee received 
multiple exams on the date in question. The Plan denied your request. The Plan says a National Correct Coding 
Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between 76937 and 76942. This PTP edit has a 
modifier indicator of 1, meaning modifiers associated with NCCI are allowed. However, an appropriate 
modifier was not billed with this PTP code edit. This service was not billed as required by Medicare coding 
regulations. 
 
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, we have confirmed that code 76942 
is a column II code to column I code 76937. This claim has not been billed with an appropriate modifier to 
bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we 
decided that the Plan does not have to pay for ultrasonic guidance for needle placement (76942) provided on 
July 27, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code(s): 82310, 82728, 83540, 
83550, and 84100) provided on July 2, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the provider did not bill as required by Medicare coding regulations. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
The documentation submitted showed that the laboratory tests reported were related to treatment of ESRD 
since end-stage renal disease was indicated as a reason for the laboratory tests, and a separate professional visit 
unrelated to ESRD was not indicated in the medical record. Therefore, the laboratory tests are included in the 
dialysis services. Based on this information, we decided that Medicare rules for coverage of the laboratory 
services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
(CPT code(s): 82310, 82728, 83540, 83550, and 84100) provided on July 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Orencia Clck 125mg/ml injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says the enrollee will self-inject the medication at home; therefore, the enrollee does not 
meet Medicare part B criteria. 
 
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 Orencia Clck 125mg/ml 
injection.  
 
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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the testing services rendered on October 13, 2021. 
 
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 correctly. 
 
The Plan must follow Medicare rules. The rules say that claims must be billed with the most precise diagnosis 
code. 
 
 
 We looked at the file and Medicare rules. The file shows that the services were not billed with an appropriate 
primary diagnosis code. 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 testing services 
rendered on October 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laryngoscopy rendered on October 5, 2021. 
 
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 procedure code 31575 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 31575 (diagnostic laryngoscopy) and 31615 
(tracheobronchoscopy through established tracheostomy incision). Code 31575 is a column II code with a 
modifier indicator of 1 when billed with column I code 31615. Code 31575 was not billed with an appropriate 
modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the 
laryngoscopy rendered on October 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement services (CPT code 11721-59) provided on 
January 17, 2022. 
 
You asked the Plan to pay for he services. You say that the services are supported, and the claim should be 
paid. The Plan denied your request. The Plan says the services are not covered as billed. 
 
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 the services have not been met. The procedure will remain denied 
for mutually exclusive procedure-to-procedure edit with Column One CPT codes 11055-11057 (Paring or 
cutting of benign hyperkeratotic lesion[s]) and Column Two CPT codes 11720-11721 (Debridement of nail(s) 
by any method). According to the documentation, the patient presented for foot care. The documentation does 
not clearly indicate that the debridement of nails and paring/cutting of lesions were performed at separate sites. 
Therefore, these codes would not be separately reported as the criteria for modifier 59 has not been met. 
Additionally, NCCI states modifier 59 may only be used to bypass, if 1 to 5 nails are debrided and a 
hyperkeratotic lesion is pared on a toe other than 1 with a debrided toenail or the hyperkeratotic lesion is 
proximal to the skin overlying the distal interphalangeal joint of a toe on which a nail is debrided. Therefore, 
we decided that the Plan does not have to pay for the debridement services (CPT code 11721-59) provided on 
January 17, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM) 
sensor (K0553). 
 
You asked the Plan to pre-approve a Freestyle Libre CGM sensor. You say that that this is medically necessary. 
The Plan denied your request. The Plan says you do not meet prior authorization criteria. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood 
glucose testing at least four times per day or use insulin with at least three daily injections. Based on this 
information, we decided that Medicare rules for coverage of a Freestyle Libre CGM sensor have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor 
(CGM) sensor (K0553).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Victoza 18 MG/3ML injection. 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says Victoza 18 MG/3ML is on the self-administered drug list and is excluded from 
coverage under Part B. 
 
 
 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 Victoza 18 MG/3ML 
injection.  
 
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the patient's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was 
admitted for myocardial infarction, congestive heart failure, and urinary tract infection. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy 
program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a 
need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able 
to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis; unilateral (CPT 
code 77061) provided on November 12, 2021. 
 
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. 
The Plan says the service is not covered 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. 
 
CPT code 77061 has a status code of "I", which is not valid for Medicare purposes. Medicare uses another code 
for reporting of and payment for these services. Based on this information, we decided that Medicare rules for 
coverage of the service have not been met. Therefore, we decided that the Plan does not have to pay for the 
diagnostic digital breast tomosynthesis; unilateral (CPT code 77061) provided on November 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for SNF services provided from March 23, 2019, through  
June 15, 2019. 
 You asked the Plan to pay for SNF services. The Plan denied your request. The Plan says the member was 
under private pay and not at a skilled nursing level of care for dates of service of March 23, 2019, through 
May 1, 2019 and the member was enrollee in Hospice from May 2, 2019, through June 15, 2019. 
 
The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from 
trained medical or paramedical staff, is not covered. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of SNF services for dates of service of March 23, 2019, through May 1, 2019 have not been met. 
Specifically, we find that the services at issue in this case are considered custodial in nature. The enrollee was 
under the Medicare hospice benefit for the dates of service May 2, 2019, through June 15, 2019. Therefore, we 
decided that the Plan does not have to pay for SNF services provided from March 23, 2019, through 
June 15, 2019.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for an electrocardiogram (93005) provided on 
December 17, 2021. 
 
You asked the Plan to waive the deductible for an electrocardiogram. You say that this was part of your annual 
physical. The Plan denied your request. The Plan says this processed appropriately. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $150 deductible which applies to most Part B services.  
 
The item or service you asked the Plan to waive the deductible for is a Part B services. The Plan has followed 
Medicare rules by clearly disclosing in the contract that there is a $150 deductible which applies to most Part B 
services. This cost sharing is a contractual obligation that had not been met at the time an electrocardiogram was received on December 17, 2021. Therefore, we decided that the Plan does not have to waive the deductible 
for an electrocardiogram (93005) provided on December 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a laparoscopic sleeve gastrectomy procedure. 
 
You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says you 
have not had a documented physical activity or exercise program. 
 
The Plan follows Medicare rules. Medicare rules say that a laparoscopic sleeve gastrectomy is only covered 
under certain medical indications.  
 
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 requested services. Our physician 
reviewer found that you have a BMI of 47 kg/m2, and multiple obesity-related co-morbid conditions including 
GERD, depression, hypertension, diabetes, and degenerative joint disease.  It is documented that you exercise rarely. You completed 12 months of supervised weight loss, as well as 
dietary evaluation. The monthly Medical Weight Loss Progress Notes do not document any physical activity or 
exercise plan. The documentation in the case file does not support that all of the coverage criteria have been 
met in this case.   
 
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 requested services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a laparoscopic sleeve gastrectomy procedure.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT code(s): A9576, 36415, 82565, 77066, 
G0279, 76642, and 77049) provided on October 29, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not covered as billed. 
 
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 the services have not been met.  For this billing denial, CPT code 
77049 denied per OCE Edit 062 for a code not recognized by Medicare for OPPS. Per the guidelines we find 
the Medicare rule for payment of this October 29, 2021, claim has not been met. Therefore, we decided that the 
Plan does not have to pay for the services (CPT code(s): A9576, 36415, 82565, 77066, G0279, 76642, and 
77049) provided on October 29, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from January 16, 2022, 
through January 18, 2022. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically 
necessary. The Plan denied your request. The Plan says that the inpatient care does not meet the MCG 
guidelines. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record indicates that you were admitted with chest pain in the setting of recurrent 
paroxysmal atrial fibrillation with rapid ventricular response. The record indicates that at the time of admission 
you had persistent tachycardia and atrial fibrillation. Additional information was received that cardioversion 
was planned. The record is sufficient that the treating physician had a reasonable expectation of a length of stay 
spanning 2 or more midnights. The elements of the coverage rule are satisfied.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from January 16, 2022, through January 18, 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.