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

 
We decided that the Plan does not have to pay for the critical care services rendered on July 10, 2021 to July 
11, 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 99291 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 99291 is critical care, evaluation and management of the 
critically ill or critically injured patient; first 30-74 minutes. 
 
 
 We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of 
30-74 minutes of critical care services. 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 critical 
care services rendered on July 10, 2021 to July 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the stool pathogen testing provided on May 10, 2021. 
 
You asked the Plan to pay for the stool pathogen testing. You say that this is medically necessary testing 
ordered by the treating provider. The Plan denied your request. The Plan says the POS code reported does not 
match the location at which the sample was collected. 
 The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the stool pathogen testing have not been met. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided 
that the Plan does not have to pay for the stool pathogen testing provided on May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (86703-90, 84403-90, 80074-90, 85025-90, 
84153-90, 80061-90, 80053-90, 84443-90, 83036-90, 82306-90) provided October 1, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says insufficient records were provided to support the billed services. 
 
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 lab services (86703-90, 84403-90, 
80074-90, 85025-90, 84153-90, 80061-90, 80053-90, 84443-90, 83036-90, 82306-90) provided October 1, 
2021. have been met. No office notes were provided to show why this testing was ordered or to support 
medical necessity. Additional records were requested by the plan and none were provided. Therefore, we 
decided that the Plan does not have to pay for lab services (86703-90, 84403-90, 80074-90, 85025-90, 84153-
90, 80061-90, 80053-90, 84443-90, 83036-90, 82306-90) provided October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the shingles vaccine rendered on January 3, 2022. 
 
You asked the Plan to pay for these services. You say that you thought the vaccine would be less expensive at 
your physician's office. The Plan denied your request. The Plan says the services are not covered. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide these services. The 
Plan follows the same rules.  
 
 
 Records do not show that you have been injured or directly exposed to any illness related to these services. 
Therefore, we decided that the Plan does not have to pay for the shingles vaccine rendered on January 3, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the foam dressing wound cover rendered on February 8, 
2022. 
 
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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of P are 
bundled/excluded codes. 
 
 
 
 
 
 We looked at the file and Medicare rules. Billed procedure code A6212 has a status indicator of P and is not 
separately paid. Therefore, we decided that the Plan does not have to pay for the foam dressing wound cover 
rendered on February 8, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for therapy services, office visits, x-rays, and foot inserts 
provided from December 7, 2021, through December 29, 2021. 
 
You asked the Plan to pay for therapy services, office visits, x-rays, and foot inserts. The Plan denied your 
request. The Plan says the Plan only covers manual manipulation of the spine to correct subluxation, which was 
paid. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that 
the Plan does not have to pay for therapy services, office visits, x-rays, and foot inserts provided from 
December 7, 2021, through December 29, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0013M) provided October 27, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that the services were medically necessary. The Plan 
denied your request. The Plan says this service is non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare has reaffirmed non-coverage for 
CXBladder testing (0012M, 0013M). 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. This service was non-covered as of the date of service. Based on this 
information, we decided that Medicare rules for coverage of the genetic testing have not been met. Therefore, 
we decided that the Plan does not have to pay for genetic testing (0013M) provided October 27, 2021.
Appeal type: Imaging
Decision: Partially Favorable

 
We decided that the Plan has to pay for the services. We decided that the Plan does not have to pay for the rest 
of the imaging services.  
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that the 
requested services are not in accordance with accepted standards of medical practice. 
 
 
 
 We decided that the Plan has to pay for CPT 74230.  
 
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 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 for CPT 74230. Our reviewer says that a single CPT 
code - 74230 - should have been billed with includes scout films, swallowing evaluation, and delayed films if 
indicated. 
 
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 pay for 
CPT 74230.  
 
We also decided that the Plan does not have to pay for the rest of the imaging services. 
 
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 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 for the rest of the codes. Our reviewer says that the 
other billed charges are included in CPT 74230, and should not be reimbursed separately. 
 
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 rest of the imaging services have not been met. Therefore, we decided that 
the Plan does not have to pay for the rest of the imaging services. 
 
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 the spinal injection provided on December 13, 2021. 
 
You asked the Plan to pay for the spinal injection. You say that this was denied using epidural injection rules, 
and the injection provided is subarachnoid. This treatment was necessary for the enrollee's condition. The Plan 
denied your request. The Plan says the records provided do not support medical necessity. 
 
The Plan must follow Medicare rules. Medicare rules say that Medicare requires that services 
provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in 
accordance with Medicare's policies. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the spinal injection have not been met. Specifically, the documentation submitted does not include 
a valid signature from the persons responsible for the care of the beneficiary.  Review of the progress note shows that the field for electronic signature is blank, and the only potential 
signature is typed and undated. In addition, the progress note does not have a date of service specified, meaning 
it cannot be confirmed that this note is for the services provided on the date of service at issue. Therefore, we 
decided that the Plan does not have to pay for the spinal injection provided on December 13, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the requested admission to a SNF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to a SNF does not meet 
criteria. 
 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 pre-approve SNF care. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found you do not have documented skilled nursing 
needs or documented skilled therapy needs. You are not shown to be functioning significantly below his 
baseline. Your care needs, custodial and intermittent, can, as a practical matter, be provided at 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 pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Adjacent tissue transfer, or rearrangement (14301) 
provided on September 22, 2021. 
 
You asked the Plan to pay for code 14301. You say that the medical records support the billing of code 14301 
provided on September 22, 2021. The Plan denied your request. The Plan says the medical records do not 
support the billing of code 14301 provided on September 22, 2021. 
 
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 14301 is Adjacent tissue transfer or rearrangement, any 
area; defect 30.1 sq cm to 60.0 sq cm. 
 
 
 
 We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for code 14301. Our reviewer says that the medical records do 
not support the billing of code 14301 provided on September 22, 2021. Our reviewer found the documentation 
submitted was reviewed, and the operative report does not document healthy skin and other tissues transferred 
or transplanted to the area adjacent to a skin defect. Therefore, this code cannot be verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 14301 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Adjacent tissue transfer, or rearrangement (14301) provided on September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81455) provided November 11, 2021. 
 
You asked the Plan to pay for the lab services. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria was not met. 
 The Plan follows Medicare rules. Medicare rules say that genetic testing is covered when the biomarkers have 
proven clinical utility. 
 
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 lab services. Our reviewer says that the 
testing performed was not medically necessary. Our physician reviewer found the records provided do not 
support that the liquid biopsy panel performed was medically necessary for the clinical management of the 
enrollee. 
 
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 lab services have not been met. Therefore, we decided that the Plan does not 
have to pay for lab services (81455) provided November 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Hurry Cane Freedom Edition folding cane (E1399). 
 
You asked the Plan to pre-approve a folding cane. You say that you need this requested cane. You also say it is 
flexible and you can use it on different ground conditions such as gravel and grass. The Plan denied your 
request. The Plan says there is no medical reason why you need this specific brand/model of cane and why a 
standard cane would not meet your needs. 
 
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 folding cane. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found there is no clinical documentation to support this specific assistive device as being medically 
necessary. There is no supporting documentation that states why you would not be able to use either a single 
point or quad cane. 
 
 
 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 folding cane have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a Hurry Cane Freedom Edition folding cane (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on July 7, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says these services are unlikely to impact therapeutic decision-making in the clinical management of 
the patient. 
 
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 pay for the services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the requested testing is not likely to have a significant impact on treatment decisions in the clinical 
management of the member. The requested genetic testing 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 the services have not been met. Therefore, we decided that the Plan does not 
have to pay for laboratory services provided to the enrollee on July 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing services provided to the enrollee on May 10, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says the denied codes remain not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
 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. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for drug testing services provided to the enrollee on May 10, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Injectafer (ferric carboxymaltose) injections. 
 
You asked the Plan to pre-approve the treatment with Injectafer. You say that you feel this should be covered 
to treat your condition. The Plan denied your request. The Plan says the preferred drugs have not been tried, 
and there is no indication they are not appropriate for you. 
 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 the treatment with Injectafer. Our 
reviewer says that the requested drug is not shown to be reasonable and necessary based on step therapy 
criteria. Our physician reviewer found the Plan requires a trial of drug Ferrlecit, Infed, or Venofer before they 
will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is 
no documentation provided indicating that the plans required drug(s) would likely be less effective and/or 
likely have adverse effects for the enrollee. 
 
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 treatment with Injectafer have not been met. Therefore, we decided that the 
Plan does not have to pre-approve Injectafer (ferric carboxymaltose) injections.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for chemotherapy services (96375, 96411, 96413, 96416 ) 
provided on July 26, 2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says these services are not supported as billed. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of the denied codes is: 
 
Current Procedural Terminology (CPT) + 96375 Therapeutic, prophylactic, or diagnostic injection (specify 
substance or drug); each additional sequential intravenous push of a new substance/drug (List separately in 
addition to code for primary procedure) 
 
Current Procedural Terminology (CPT) + 96411 Chemotherapy administration; intraenous, push technique, 
each additional substance/drug (List separately in addition to code for primary procedure) 
 
Current Procedrual Terminology (CPT) 96413 Chemotherapy administration, intravenous infusion technique; 
up to 1 hour, single or initial substance/drug 
 
Current Procedural Terminology (CPT) 96416 Chemotherapy administration, intravenous infusion technique; 
initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable 
pump 
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found that in terms of CPT 96375 and CPT 
96411, the provider is reporting this procedure as an add on code for CPT 96413. In this case, CPT 96413 is 
not supported by the procedure report, as a start and stop time is not documented, and the primary procedure 
code cannot be verified, this procedure would not be covered. In terms of CPT 96413 and 96416, the procedure 
report does not include documentation to confirm start and stop time, and therefore these procedures cannot 
verified. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not 
have to pay for chemotherapy services (96375, 96411, 96413, 96416 ) provided on July 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder testing rendered on November 8, 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 are not covered. 
 
The Plan must follow Medicare rules. The rules say that the Cxbladder testing is non-covered. 
 
 
 
 
 
 
 
 
 
 We looked at the file and Medicare rules. The test at issue is Cxbladder. This test is not covered by Medicare. 
Therefore, we decided that the Plan does not have to pay for the Cxbladder testing rendered on November 8, 
2021.