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

 
We decided that the Plan does not have to pay for the services provided on August 2, 2022, by an out-of-
network (OON) provider. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
authorized. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The requested provider in this case is not a network provider with the Plan. The Plan had network providers 
available who could have provided the services at issue in this appeal. The Plan did not pre-approve the 
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we 
decided that the Plan does not have to pay for the services provided on August 2, 2022, by an out-of-network 
(OON) provider.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77061 billed for date of service May 13, 
2022. 
 
You asked the Plan to pay for procedure code 77061. You say that this should be paid for. The Plan denied 
your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 77061 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 77061 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 77061 billed for date of service May 13, 2022.
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 records provided support the need for SNF care. 
The Plan denied your request. The Plan says the enrollee does not need daily skilled therapy services to be 
provided by a skilled therapist in an inpatient setting. The Plan says that the enrollee has no daily skilled 
nursing needs. The Plan says that the services needed can safely be received in other settings. 
 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 the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have documented skilled nursing needs.  The enrollee does not 
have documented skilled therapy needs.  The enrollee appears to be functioning at/near her baseline.  Daily 
skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollees 
condition.  The enrollees care needs 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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reduce the copayment for urgent care services provided on May 31, 
2022. 
 
You asked the Plan to reduce the copayment for urgent care services. You say that it is not fair that this 
copayment has doubled since last year. The Plan denied your request. The Plan says this cost sharing was 
charged correctly. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 
copayment for urgent care services. 
 
You have been asked to pay a $40 copayment for urgent care services. This item/service falls within the urgent 
care services benefit category. This means that you have been asked to pay the correct amount based on your 
contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the 
Plan.  Therefore, we decided that the Plan does not have to reduce the copayment for urgent care services 
provided on May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the therapy services provided on June 16, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not payable 
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. 
 
 
We find that payment for CPT code 92597 is not supported in the medical record. Specifically, code 92597 is 
assigned a PC/TC indicator of 7. This means that payment may not be made if the service is provided to either 
a patient in a hospital outpatient department or to an inpatient of the hospital by an independently practicing 
physical or occupational therapist. 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 therapy 
services provided on June 16, 2022.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the services (70490) provided on May 5, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the claim was 
billed with the incorrect place of service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan argues that the claim was billed with the incorrect place of service. In 
this case, the claim was billed with place of service 22. The Plan has not provided evidence showing that place 
of service 22 is incorrect in this case, as the services were provided in an outpatient facility. Without supporting 
documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the 
services (70490) provided on May 5, 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.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the acute inpatient hospital care provided from March 16, 
2022, to March 23, 2022. 
 
  You asked the Plan to pay for the acute inpatient hospital care. You say that you would like this claim to be 
paid in full because the enrollee required surgery for repair of fractures and rehabilitation post operation. The 
Plan denied your request. The Plan says the documentation does not show that the enrollee did not get better 
within 48 hours and still had other serious injuries that needed to be watched, or had bone break through the 
skin and needed intravenous antibiotics. The Plan also says that the documentation does not show that the 
fracture was unstable, that blood vessels were injured, or that the enrollee needed pain medicine many times 
through a vein. 
 
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 the acute inpatient hospital care. Our 
reviewer says that the documentation does not support that the criteria for inpatient payment are met in this 
case. Our physician reviewer found the enrollee presented to the hospital and had closed fractures of distal tibia 
and fibula. This is a request for hospital services following surgical repair. Our reviewer found that the enrollee 
was given morphine, underwent surgical open reduction and internal fixation (ORIF) procedure with external 
fixation without complication and they transitioned quickly to oral. The procedure was not complex or 
requiring multiple surgeries, and the enrollee was stable. Our physician reviewer also found that there was no 
suggestion the enrollee required hospital services that would likely have crossed 2 midnights.  
 
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 acute inpatient hospital care have not been met. Therefore, we decided that 
the Plan does not have to pay for the acute inpatient hospital care provided from March 16, 2022, to March 23, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for definitive drug testing (G0481) provided on March 23, 2022. 
 You asked the Plan to pay for drug testing. You say that this testing was medically necessary and is supported 
as billed. The Plan denied your request. The Plan says there is insufficient information to process this claim for 
payment. 
 
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 drug testing have been met. 
Specifically, the records provided do not include any information from the referring provider such as progress 
notes or a signed order to show that these services were medically necessary and were requested by the 
enrollee's treating physician. Therefore, we decided that the Plan does not have to pay for definitive drug 
testing (G0481) provided on March 23, 2022.
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided on July 8, 2022. 
 
You asked the Plan to pay for the ambulance services. The Plan denied your request. The Plan says Original 
Medicare would be responsible for payment of all Medicare covered services related or unrelated to the 
members terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all 
hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-
for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until 
the first day of the month following the month in which hospice was revoked or discharged. 
 
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.  The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for ambulance services provided on July 8, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a pneumatic compression device (E0676) and segmental 
pneumatic appliance (E0673) provided April 29, 2022. 
 
You asked the Plan to pay for a pneumatic compression device and appliance. You say that the enrollee's 
physician has prescribed the use of a pneumatic compression device to prevent the formation of blood clots. 
The Plan denied your request. The Plan says pneumatic compression device is not covered by Medicare to 
prevent deep vein thrombosis during and/or following surgery. 
 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. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules.The enrollee used the equipment in the facility during and/or after 
surgery. Payment for this service would have been included under the facility claim. Payment for this service is 
the responsibility of the facility or hospital that provided the surgery. 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 a pneumatic compression device (E0676) and segmental pneumatic appliance (E0673) 
provided April 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urine polymerase chain reaction (PCR) panel provided on 
May 10, 2022, billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 87653, 87591, 87640, 
87641, 87651, 87653, 87661 and 87798. 
 
You asked the Plan to pay for the urine PCR panel. You say that these services were medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that a test panel cannot be unbundled and billed as 
individual components regardless of the fact that the test reports multiple individual pathogens and/or targets. 
 
We looked at the file and Medicare rules. This was a panel that was not billed with a single panel code as 
required. Based on this information, we decided that Medicare rules for coverage of the urine PCR panel have 
not been met. Therefore, we decided that the Plan does not have to pay for the urine polymerase chain reaction 
(PCR) panel provided on May 10, 2022, billed with codes 87481, 87491, 87496, 87500, 87511, 87529, 87532, 
87653, 87591, 87640, 87641, 87651, 87653, 87661 and 87798.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99100 billed for date of service June 23, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that this claim was billed with an anesthesia 
code, and this is the correct modifier to use per CMS guidelines. You say that the medical records should be 
reviewed, and the claim reprocessed for payment. The Plan denied your request. The Plan says procedure code 
99100 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
  We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service June 23, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided to the enrollee from April 
7, 2022, to May 6, 2022. 
 
You asked the Plan to pay for home health services. You say that you disagree with the Plan's denial. The Plan 
denied your request. The Plan says the services are not payable as billed. 
 
The Plan must follow Medicare rules. The rules say that certain data elements on the NOA 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, the period of 
care claim does not match the one-time artificial admission ate from the NOA claim from the first period of 
continuing care in 2022. Therefore, we decided that the Plan does not have to pay for the home health services 
provided to the enrollee from April 7, 2022, to May 6, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service April 22, 
2022. 
 
You asked the Plan to pay for procedure code S2900. You say that this is supported in the operative report. The 
Plan denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service April 22, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on May 23, 2022, billed with 
codes 81218, 81201, 81209, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 81334, 81351, 81406 and 
81437. 
 
You asked the Plan to pay for the genetic testing billed. You say that this test was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
 We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed 
have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
May 23, 2022, billed with codes 81218, 81201, 81209, 81292, 81295, 81298, 81307, 81314, 81317, 81321, 
81334, 81351, 81406 and 81437.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for occupational therapy services billed for date of service 
February 23, 2021. 
 
You asked the Plan to pay for occupational therapy services. You say that the services at issue were 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 the services of an OTA shall not be billed as 
services incident to a physician/NPP's service, because they do not meet the qualifications of a therapist. 
 
 
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of occupational therapy services have not been met. Specifically, the case record documents that the 
OTA services at issue have been billed incorrectly as services incident to a physician/NPP's service. Therefore, 
we decided that the Plan does not have to pay for occupational therapy services billed for date of service 
February 23, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the debridement services provided on April 12, 2022. 
 
You asked the Plan to pay for the debridement services. You say that you disagree with the Plan's denial. The 
Plan denied your request. The Plan says that invalid modifier identified for the service. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. Review of the file shows that the Plan has denied this claim due to the provider 
billing the incorrect modifier. No additional information was provided to support this argument. The Plan did 
not explain why there was an incorrect modifier billed. The Plan did not substantiate their denial. Therefore, we 
decided that the Plan has to pay for the debridement services provided on April 12, 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.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the emergency department visit coded 99285 provided on 
June 6, 2022. 
 
You asked the Plan to pay for the emergency department visit. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the claim is not payable 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. 
 
We find that CPT code 99285 is not supported in the medical record. Specifically, this code was billed with 
diagnosis codes M60.9 (myositis, unspecified) and M32.9 (systemic lupus erythematosus, unspecified). These 
two diagnosis codes should not be reported together. This means the claim is not payable as billed. Based on 
this information, we decided that Medicare rules for coverage of the emergency department visit have not been 
met. Therefore, we decided that the Plan does not have to pay for the emergency department visit coded 99285 
provided on June 6, 2022.