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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service September 
23, 2022. 
 You asked the Plan to pay for procedure code 70450. You say that the enrollee had multiple exams on the date 
in question. The Plan denied your request. The Plan says payment for code 70450 is bundled into payment for 
code 70496. 
 
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 70450 
is a column II code to column I code 70496. 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 procedure code 70450 billed for date of service September 23, 
2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99306 billed for date of service February 25, 
2022. 
 You asked the Plan to pay for procedure code 99306. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says payment for code 99306 is bundled into payment for code 90791. 
 
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 99306 
is a column II code to column I code 90791. 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 procedure code 99306 billed for date of service February 25, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service July 28, 2022. 
 
You asked the Plan to pay for procedure codes 87481, 87653 and 87798. You say that these services were 
reported correctly. The Plan denied your request. The Plan says these services are not supported for separate 
payment, as they are included in code 87801. 
 
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 codes 87481 and 87653 are column II codes to column I code 87801. 
These services have not been billed with an appropriate modifier to bypass the edit. Based on the claim 
submitted, Medicare billing criteria have not been met for codes 87481 and 87653. In addition, we have 
confirmed that code 87798 is a column II code to column I code 87801; however, 87798 was billed with a 
modifier.  
 
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 procedure code 87798. Our reviewer says that modifier 91 is 
not supported for separate payment of this service. Our reviewer found the documentation does not show that 
lab tests were repeated to obtain subsequent/multiple test results. The record supports that the tests performed 
are included in 87801, there is no need to report them separately with a modifier. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure codes 87481, 87653 and 87798 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure codes 87481, 87653 and 87798 billed for date of 
service July 28, 2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve psychological and neuropsychological testing (codes 
96121 x2, 96133 x5, 96137 x5, 96139 x5). 
 
You asked the Plan to pre-approve psychological and neuropsychological testing. You say that the enrollee is 
having progressive decline in memory and behavior. The Plan denied your request. The Plan says the requested 
additional hours of special testing are not approved. The Plan also says to have additional hours approved, all 
the criteria in the guideline would have to be met. 
 
The Plan follows Medicare rules. Medicare rules say that supporting documentation in the medical record must 
be present to justify greater than 8 hours per patient per evaluation. 
 
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 psychological and neuropsychological 
testing (codes 96121 x2, 96133 x5, 96137 x5, 96139 x5). Our reviewer says that the psychological and 
neuropsychological testing is not medically reasonable and necessary. Our physician reviewer found the 
records indicated that prior testing had been done and that conclusions had been made on the enrollee's 
status/condition. Supporting documentation was not provided for review to support a need for additional hours 
of testing. Our reviewer also found that as conclusions had previously been made/reached and no explanation 
was provided for a need for additional testing, this would not meet the requirements for coverage. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of psychological and neuropsychological testing (codes 96121 x2, 96133 x5, 
96137 x5, 96139 x5) have not been met. Therefore, we decided that the Plan does not have to pre-approve 
psychological and neuropsychological testing (codes 96121 x2, 96133 x5, 96137 x5, 96139 x5).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for validity testing billed with code 83789 for date(s) of service 
October 7, 2022. 
 
You asked the Plan to pay for code 83789. You say that this service is medically necessary and should be paid. 
The Plan denied your request. The Plan says code 83789 is not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers performing validity testing on urine 
specimens utilized for drug testing should not separately bill the validity testing. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of code 83789 have not been met. Specifically, we find that the testing described by code 83789 is not 
separately payable. Therefore, we decided that the Plan does not have to pay for validity testing billed with 
code 83789 for date(s) of service October 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to issue reimbursement for the complete lower denture (D5120) 
provided on April 5, 2022. 
 
You asked the Plan to issue reimbursement for this item. You say that you are requesting a reconsideration of 
the Plan's denial for payment. The Plan denied your request. The Plan says your benefit for the item provided 
has already been exhausted. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, certain limitations apply. The record 
shows your benefit for the item provided was exhausted on date of service July 10, 2020. Specifically, the Plan 
contract states that prosthetics are limited to one per arch every five years. You previously received a complete 
lower denture on July 10, 2020, less than five years prior, which was paid for by the Plan. Therefore, you have 
exhausted the allowable benefit for this item. Therefore, we decided that the Plan does not have to issue 
reimbursement for the complete lower denture (D5120) provided on April 5, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the nerve conduction studies (NCS) and electromyography 
(EMG) provided on September 26, 2022, billed with codes 95908 and 95885. 
 
You asked the Plan to pay for the nerve conduction studies (NCS) and electromyography (EMG) provided on 
September 26, 2022, billed with codes 95908 and 95885. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the records submitted do not support procedure codes 95908 and 
95885. 
 
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 Codes Manual definition of codes 95908 and 95885 is nerve conduction test; 3-4 studies 
and needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve 
conduction, amplitude and latency/velocity study; limited. 
 
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 nerve Conduction Test; 3-4 studies and needle 
electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, 
amplitude and latency/velocity study; limited. Our reviewer says that the record does not support that 95885 
and 95908 were separately identifiable services. These are included in the codes for intraoperative 
neuromonitoring. Our reviewer found the records submitted do not support procedure codes 95908, 95885-26-
RT, and 95885-26-LT. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of nerve Conduction Test; 3-4 studies and needle electromyography, each 
extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude, and 
latency/velocity study; limited. have not been met. Therefore, we decided that the Plan does not have to pay for 
the nerve conduction studies (NCS) and electromyography (EMG) provided on September 26, 2022, billed 
with codes 95908 and 95885.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency 
transport provided on September 13, 2022. 
 
You asked the Plan to pay for the ambulance service, basic life support, non-emergency transport. You say that 
the medical records provided support the need for the ambulance transport. The Plan denied your request. The 
Plan says the ambulance transport was 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 service, basic life support, 
non-emergency transport. Our reviewer says that the ambulance transport was not medically necessary.  
 Our physician reviewer found the transportation via ambulance from the hospital to a retirement community 
was not medically necessary. The enrollee was not bedbound, as evidence their ability to stand-pivot-transfer. 
The enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance 
in order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van, 
wheelchair van, private car, taxi) without endangering the enrollee's 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 the ambulance service, basic life support, non-emergency transport have not 
been met. Therefore, we decided that the Plan does not have to pay for the ambulance service, basic life 
support, non-emergency transport provided on September 13, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you would like reconsideration based on the records 
submitted. The Plan denied your request. The Plan says you do not meet the guidelines for IRF services. 
 
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 your nursing, medical, and rehabilitation needs does not require an 
IRF stay. You were admitted for a fall, leg pain, and lower extremity hematoma. Your medical problems are 
stable, and you have no complex nursing or rehabilitation needs.  You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, 
and an intensive rehabilitation therapy program. While you may have a need for physical therapy and/or 
occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary 
care can be provided in a different level of care. There is not a reasonable expectation that you 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 an IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0676) provided on June 
8, 2022. 
 
You asked the Plan to pay for the pneumatic compression device. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the item rendered is not a covered benefit. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service.  
 
 
 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0676) provided on June 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services provided on July 12, 2022. 
 
You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says you billed with an 
incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 lab 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 the lab services provided on July 12, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services billed for dates of service from June 28, 
2022, to July 27, 2022. 
 
You asked the Plan to pay for home health services. You say that the services at issue have been billed 
correctly. The Plan denied your request. The Plan says rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that patient status code 06 should be reported in all 
cases where the HHA is aware that the period of care will be paid a partial period payment adjustment. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of home health services have not been met. Specifically, the patient status code reported is 06, 
indicating a partial period of care. The dates of service reported describe a full 30-day period of care. The 
patient status code conflicts with the reported dates of service. Therefore, we decided that the Plan does not 
have to pay for home health services billed for dates of service from June 28, 2022, to July 27, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that you find that the LTACH level of care is 
most appropriate for the enrollee to achieve the best outcome due to their complex medical needs. The Plan 
denied your request. The Plan says criteria for admission to the LTACH have not been met. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 LTACH services. Our reviewer 
says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee appears to be more stable but weaning potential is still not clear and they 
require short-term additional acute care hospital services that can safely be provided at the current facility until 
more stable and appropriate for transfer. There are no services at the LTACH that the enrollee requires that are 
not already available and covered at the current facility. Transfer to the LTACH would not be clinically 
advantageous and completion of treatment at the current facility is recommended. 
 
 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 LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a repeat epidural steroid injection (ESI) (64483). 
 
You asked the Plan to pre-approve a repeat ESI. You say that the enrollee would like to repeat the injection. 
You also say that the enrollee would like to avoid surgery if possible. The Plan denied your request. The Plan 
says the requested injection is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a repeat ESI may be considered medically reasonable 
and necessary when the medical record documents that the first injection provided at least 50% of sustained 
improvement in pain relief for three months. 
 
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 repeat ESI. Our reviewer says that a 
repeat ESI is not medically necessary. Our physician reviewer found the provided documentation does not 
indicate that the enrollee had at least 50% pain relief for three months. Therefore, the reviewer found that a 
repeat ESI 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 a repeat ESI have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a repeat epidural steroid injection (ESI) (64483).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve folfiri and cetuximab. 
 
You asked the Plan to pre-approve folfiri and cetuximab. You say that the service is medically necessary. The 
Plan denied your request. The Plan says the service is not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 
drugs if they are medically accepted as safe and effective or appropriate for the particular use.  
 
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 folfiri and cetuximab. Our reviewer 
says that the service is not medically necessary. Our physician reviewer found the requested use of this drugs is 
not FDA-approved for the enrollees diagnosis or supported in any compendia. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of folfiri and cetuximab have not been met. Therefore, we decided that the Plan 
does not have to pre-approve folfiri and cetuximab.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 3 office visits with this out-of-network pain 
management specialist. 
 You asked the Plan to pre-approve specialist services. You say that you have been on pain medication for a 
long time due to your health issues. You say that you have been with the pain management doctor for over a 
year. You also say that you would like to continue with this provider. The Plan denied your request. The Plan 
says there are network providers available. 
 
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan 
providers available to meet enrollees needs. Your contract with the Plan says that, with few exceptions, you 
must use contract providers for care.  
 
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 specialist services. Our reviewer says 
that the request to see an out-of-network pain specialist is not medically necessary. Our physician reviewer 
found the Plan has adequate network pain specialists that can provide these services. The reviewer found that 
there is not anything unique about the enrollee's condition that that would make it medically necessary for them 
to see the requested out-of-network provider. Therefore, the reviewer found that the request to see an out-of-
network pain specialist 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 specialist services have not been met. Therefore, we decided that the Plan does 
not have to pre-approve 3 office visits with this out-of-network pain management specialist.