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

 
We decided that the Plan does not have to pay for the laboratory services provided on June 14, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. 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 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 laboratory 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 laboratory services provided on June 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan 
denied your request. The Plan says based on the documentation provided, coverage criteria has 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 medical record does not indicate that the enrollee requires services that they are 
not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules 
are not satisfied. The requested service cannot be 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on August 23, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. 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 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 laboratory 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 laboratory services provided on August 23, 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 received oral medications, had stable vital 
signs and your lungs were clear. You were at a supervision / stand by assist level with functional mobility 
including gait to 300 feet. You do not require skilled nursing or therapy services on a daily basis. You do not 
meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (0242U) provided April 14, 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 the documentation does not support the billed services. 
 
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 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 lab services (0242U) provided April 14, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dry needling services provided from September 28, 2021, 
to November 2, 2021. 
 
You asked the Plan to pay for the dry needling services. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says dry needling is not covered by Medicare 
or the Plan for your diagnosis. 
 
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. 
However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture 
treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year.  
 
We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of 
the acupuncture services have not been met. Specifically, you received dry needling services to treat a strain of 
a muscle and tendon of the front wall of your chest. Acupuncture services, such as dry needling, are only 
covered for the treatment of chronic low back pain. Therefore, we decided that the Plan does not have to pay 
for the dry needling services provided from September 28, 2021, to November 2, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Hyalgan, Supartz Visco-3 injections. 
 
You asked the Plan to pre-approve Hyalgan, Supartz Visco-3 injections. You say that the services are 
necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria 
has not been met. 
 
The Plan follows Medicare rules. Medicare rules say that Medicare may cover a drug or biological if it is safe 
and effective and otherwise reasonable and necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve Hyalgan, Supartz Visco-3 injections. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found this is an off-
label use of this medication and is not supported by peer reviewed publications. Therefore, the request is 
considered 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 Hyalgan, Supartz Visco-3 injections have not been met. Therefore, we decided 
that the Plan does not have to pre-approve Hyalgan, Supartz Visco-3 injections.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705 billed for date of service November 9, 
2021. 
 You asked the Plan to pay for procedure code 76705. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 76705 is bundled into payment for 
93976. 
 
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 76705 
is a column II code to column I code 93976. 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 76705 billed for date of service November 9, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary.  The Plan denied your request. The Plan says the requested continued SNF care 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications and had stable vital signs.  She had fatigue but was otherwise asymptomatic with no fever or 
shortness of breath. The enrollee was at a maximal assist level with functional mobility. The enrollee does not 
require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or 
intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99153) provided on April 19, 
2021. 
 
You asked the Plan to pay for code 99153. You say that you would like the Plan to reconsider their denial of 
payment. 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. 
 
We looked at the file and Medicare rules. In this case, the review shows that the medical records provided 
represent professional charges; however, procedure code 99153 was provided in a facility with a place of 
service code of 22. Procedure code 99153 has a PC/TC Modifier Status of 3, which specifies a Technical Component only code. Therefore, we decided that the Plan does not have to pay for the moderate sedation 
services (99153) provided on April 19, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
October 24, 2021. 
 
You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of 
payment. 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. 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 the Computed tomography (CT) scan (70450) provided on 
October 24, 2021.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home services (S9338) provided May 20, 2021 to May 21, 
2021. 
 
You asked the Plan to pay for the home services. You say that the service was medically necessary. The Plan 
denied your request. The Plan says the code billed is not eligible for Medicare payment. 
 
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 find that CPT code S9338 is not supported in the medical record. Specifically, the code billed has a status 
of "I" per the National Physician Fee Schedule and is not valid for Medicare payment. Based on this 
information, we decided that Medicare rules for coverage of the home services have not been met. Therefore, 
we decided that the Plan does not have to pay for home services (S9338) provided May 20, 2021 to May 21, 
2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ROMTech Adaptive Rehabilitation Device and 
ROMTech Knee AccuAngle. 
 
You asked the Plan to pre-approve a ROMTech Adaptive Rehabilitation Device and ROMTech Knee 
AccuAngle. You say that the services are necessary. The Plan denied your request. The Plan says medical 
necessity has not been established. Therefore, coverage criteria have not been met. 
 
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 ROMTech Adaptive Rehabilitation 
Device and ROMTech Knee AccuAngle. Our reviewer says that the requested items/services are not 
considered medically reasonable and necessary in this case. Our physician reviewer found based on the medical 
records provided and review of current care guidelines there is no documentation that the ROMTech Adaptive 
Rehabilitation Device (HCPC E1399) in addition to the ROMTech Knee AccuAngle, Bluetooth Enabled 
Progress Monitor as a technical component (HCPC A9900) at issue in this case meet Medicare criteria for 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 a ROMTech Adaptive Rehabilitation Device and ROMTech Knee AccuAngle 
have not been met. Therefore, we decided that the Plan does not have to pre-approve a ROMTech Adaptive 
Rehabilitation Device and ROMTech Knee AccuAngle.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve use of onabotulinumtoxin-A (Botox). 
 
You asked the Plan to pre-approve Botox. You say that the enrollee needs Botox in order to treat significant 
symptoms. The Plan denied your request. The Plan says the denial of authorization for this service is correct, 
because the enrollee does not have a medically-accepted indication for Botox. 
 
The Plan follows Medicare rules. Medicare rules state that botulinum toxin products such as Botox are only 
covered for certain indicatios. 
 
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 Botox. Our reviewer says that the 
enrollee does not meet the Medicare criteria for the requested use of Botox. Our physician reviewer found the 
enrollee does not meet the covered indications for use of Botox. Gastroparesis is an off-label and insufficiently 
supported indication for Botox treatment. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to 
pre-approve use of onabotulinumtoxin-A (Botox).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
1, 2021 to April 30, 2021. 
 
You asked the Plan to pay for home health services. You say that the home health services were medically 
necessary. The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must 
be completed for home health care services to be covered. 
 
We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that 
Medicare rules for completing the claim for home health services have not been met. Specifically, a RAP claim 
was not submitted within 5 days from the start of care. Therefore, we decided that the Plan does not have to pay 
for the home health services provided to the enrollee from April 1, 2021 to April 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (0242U) provided May 12, 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 the documentation does not support the billed services. 
 
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 genetic 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 genetic testing (0242U) provided May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for pathology services (88305) provided August 13, 2021. 
 
You asked the Plan to pay for the pathology services. You say that the service was medically necessary. The 
Plan denied your request. The Plan says this service was not billed with a valid place of service. 
 
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 find that CPT code 88305 is not supported in the medical record. Specifically, payment for this service is 
included in facility payment went billed with this place of service (22, outpatient hospital). Based on this 
information, we decided that Medicare rules for coverage of the pathology services have not been met. 
Therefore, we decided that the Plan does not have to pay for pathology services (88305) provided August 13, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services (71045) provided October 10, 2021. 
 
You asked the Plan to pay for the radiology services. You say that this service was medically necessary. The 
Plan denied your request. The Plan says the code billed shares a bundled relationship with another code 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, we have confirmed that code 71045 
has a bundled relationship with code 74022. 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 radiology services (71045) provided October 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the laser destruction of incompetent vein of arm or leg 
using imaging guidance (CPT code 36478). 
 You asked the Plan to pre-approve the service. You say that you have chronic venous insufficiency complains 
of increased leg swelling. You state your swelling results in decreased ambulation and relying more on a 
wheelchair than a walker and your recent venous ultrasound showed bilateral great saphenous vein 
insufficiency and conservative measures have only seen mild improvement. The Plan denied your request. The 
Plan says your medical records received do not support that you met the following guideline for this procedure: 
1. The veins targeted for treatment do not have back up flow (reflux) of 500 milliseconds or more demonstrated 
on the ultrasound (Duplex scan). 
 
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 service. Our physician reviewer 
found not all coverage criteria are met. Additionally, it is not possible to attribute your leg symptoms to your 
varicose veins without an assessment of arterial perfusion by the vascular provider. The only note that mentions 
pulses appear to be a template and in that exam it is documented that you have no edema. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the laser destruction of incompetent vein of arm or leg using imaging guidance (CPT code 
36478).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple repair of superficial wounds of face, ears, eyelids, 
nose, lips and/or mucous membranes; 2.5 cm or less (CPT code 12011) provided on May 1, 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 supported by the records. 
 
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 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 service. Our reviewer found the reviewed documentation 
indicates that the CPT code remains denied as the wound closure was performed utilizing tissue adhesive only. 
The review has determined the service was not supported in the medical records. 
 
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 service have not been met. Therefore, we decided that the Plan does not have to pay for the simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous 
membranes; 2.5 cm or less (CPT code 12011) provided on May 1, 2021.