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

 
We decided that the Plan does not have to pre-approve stab phlebectomy of varicose veins (37765, 37766). 
 
You asked the Plan to pre-approve stab phlebectomy of varicose veins. 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 varicose vein treatment is covered when specific 
criteria are met. 
 
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 stab phlebectomy of varicose veins. 
Our reviewer says that the services are not medically necessary. Our physician reviewer found the 
documentation does not meet criteria for coverage. Coverage criteria require that there be documentation in the 
medical record of symptoms, attributable to the varicose veins, that are lifestyle limiting despite conservative 
efforts including the use of graduated compression stockings.  In this case it is documented that the enrollee has 
not been using compression stockings and there has been no follow up with respect to response to conservative 
efforts. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of stab phlebectomy of varicose veins have not been met. Therefore, we decided 
that the Plan does not have to pre-approve stab phlebectomy of varicose veins (37765, 37766).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient psychiatric services rendered from March 2, 
2022, to March 31, 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 claim was not billed correctly. 
 
The Plan must follow Medicare rules. The rules say that the hospital may bill only for services provided. 
 
We looked at the file and Medicare rules. The file shows that the dates of service on the billed claim do not 
match the number of units. 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 inpatient 
psychiatric services rendered from March 2, 2022, to March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 82435, 84132, 84295, 82465, 83721 and 
84478 billed for date of service June 11, 2021. 
 
You asked the Plan to pay for procedure codes 82435, 84132, 84295, 82465, 83721 and 84478. You say that 
these services are supported as billed. The Plan denied your request. The Plan says payment for codes 82435, 
84132, 84295, 82465, 83721 and 84478 are bundled into payment for codes 80051 and 80061. 
 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 
82435, 84132 and 84295 are column II codes to column I code 80051, and codes 82465, 83721 and 84478 are 
column II codes to column I codes 80061. 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 codes 82435, 84132, 84295, 82465, 83721 and 84478 
billed for date of service June 11, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee 
was admitted for lumbar fractures after a motor vehicle collision. The enrollee does not require treatment by 
multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation 
therapy program. While the medical record supports a need for physical and/or occupational therapy, there is 
not a reasonable expectation that she will be able to fully participate in and benefit from the intensive 
rehabilitation therapy program provided in an IRF. Medically necessary care can be provided in a different 
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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the telephone evaluation rendered on March 10, 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 procedure code 99443 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 99443 is telephone evaluation and management service 
by a physician or other qualified health care professional who may report evaluation and management services 
provided to an established patient, parent, or guardian not originating from a related E/M service provided 
within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest 
available appointment; 21-30 minutes of medical discussion. 
 
We find that CPT code 99443 is not supported in the medical record. Specifically, the file shows that procedure 
code 99213 (office visit) was billed for the enrollee on March 4, 2022, which is seven days prior to the date of 
service for code 99443. 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 telephone 
evaluation rendered on March 10, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 28, 2022 billed with 
codes 81225, 81226, 81227, 81230, 81231, 81232, 81306, 81328, 81335, 81355, 0031U, 0032U, and 0033U. 
 
You asked the Plan to pay for the genetic testing billed. 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 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 
January 28, 2022 billed with codes 81225, 81226, 81227, 81230, 81231, 81232, 81306, 81328, 81335, 81355, 
0031U, 0032U, and 0033U.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the gene panel testing provided on April 5, 2022. 
 You asked the Plan to pay for the testing services. You say that the testing enables physicians to deliver 
personalized cancer care. The Plan denied your request. The Plan says the documentation does not support the 
billed date of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  
 
We looked at the file and the rules. There are insufficient medical records from the treating physician to show 
that the coverage criteria for the billed date have been met. Therefore, we decided that the Plan does not have to 
pay for the gene panel testing provided on April 5, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab services (85610, 85730) provided on April 8, 2022. 
 
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not 
billed with an appropriate diagnosis code. 
 
The Plan must follow Medicare rules. Medicare rules say that prothrombin time testing must be billed with an 
appropriate diagnosis code.  
 
We looked at the file and Medicare rules. The testing in this case was not billed with an appropriate diagnosis 
code as required by the NCD. 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 lab services 
(85610, 85730) provided on April 8, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on October 20, 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. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. 
 
The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test 
solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory 
services provided on October 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the requested admission to an IRF is medically 
necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet 
criteria. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
 
 
 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an 
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for 
lumbar spine surgery. You do not require treatment by multiple therapies, including either physical therapy or 
occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a 
need for physical and/or occupational therapy, 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. Medically 
necessary care can be provided in a different 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 IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the exercise bike (E1399) heavy duty equipment mat 
(E1399) and warranty plan (E1399) purchased November 29, 2021. 
 
You asked the Plan to pay for the exercise equipment. You say that you feel that you should be reimbursed 
more than the $113.15 you received since you paid $1,053.92. The Plan denied your request. The Plan says 
these items are not covered benefits. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pay for the exercise bike (E1399) heavy duty equipment mat (E1399) 
and warranty plan (E1399) purchased November 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the CT scan (74178) provided on April 13, 2022. 
 
You asked the Plan to pay for the CT scan (74178). You say that the procedure was rendered in the appropriate 
place of service and the claim should be reconsidered for payment. The Plan denied your request. The Plan 
says procedure code 74178 was billed with an incorrect 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. 
 
In this case, the CPT Code Manual definition of code 74178 is computed tomography, abdomen and pelvis; 
without contrast material in one or both body regions, followed by contrast material(s) and further sections in 
one or both body regions. 
  We find that CPT code 74178 is not supported in the medical record. Specifically, the enrollee was an inpatient 
at the time of service, but the outpatient POS was billed. Based on this information, we decided that Medicare 
rules for coverage of the CT scan (74178) have not been met. Therefore, we decided that the Plan does not 
have to pay for the CT scan (74178) provided on April 13, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve insertion of an implantable loop recorder (ILR).  
You asked the Plan to pre-approve insertion of an ILR. 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 cardiac event monitors are covered when specific 
criteria are met. 
 
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 insertion of an ILR. Our reviewer says 
that the services are not medically necessary. Our physician reviewer found the enrollee has a history of 
documented atrial fibrillation. As such, based on current guidelines and the documentation provided, there is 
insufficient clinical evidence to support the medical appropriateness and necessity of replacing the enrollees 
old ILR with a new ILR. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of insertion of an ILR have not been met. Therefore, we decided that the Plan does 
not have to pre-approve insertion of an implantable loop recorder (ILR).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the severing of eye adhesions (65865 and 65870) provided 
on January 17, 2022. 
 
You asked the Plan to pay for the severing of eye adhesions (65865 and 65870). You say that modifier 59 was 
added to indicate separate procedures. The Plan denied your request. The Plan says the services were not 
considered for payment because medical records were not submitted. 
 
  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 the severing of eye adhesions (65865 
and 65870) have been met. Specifically, medical records were not submitted to determine if payment should be 
issued. Therefore, we decided that the Plan does not have to pay for the severing of eye adhesions (65865 and 
65870) provided on January 17, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CxBladder testing (0013M) provided on December 20, 2021. 
 
You asked the Plan to pay for CxBladder testing. You say that these services are necessary and supported in the 
medical record. The Plan denied your request. The Plan says this test is not covered by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare does not cover 
codes 0012M or 0013M for CxBladder. Therefore, we decided that the Plan does not have to pay for 
CxBladder testing (0013M) provided on December 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the at-home COVID-19 tests purchased on January 19, 2022. 
 
You asked the Plan to pay for the at-home COVID-19 tests. You say that you would like to be reimbursed for 
the at-home COVID-19 test you purchased. The Plan denied your request. The Plan says the claim denied 
correctly and no reimbursement is due. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for OTC items and the at-home 
COVID-19 tests is an OTC item. These tests were purchased prior to the new initiative started on April 4, 
2022, that allows eight OTC COVID-19 tests per calendar month. Therefore, we decided that the Plan does not 
have to pay for the at-home COVID-19 tests purchased on January 19, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to waive the deductible for medical vision services (99204, 92250) 
provided on April 19, 2022. 
 
You asked the Plan to waive the deductible for vision care. You say that you were not told you would owe any 
amount for these services. The Plan denied your request. The Plan says your deductible had not been met at the 
time of services. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that there is a $250 deductible which applies to Medicare-covered vision services 
excluding eyewear after cataract surgery. 
 
The item or service you asked the Plan to waive the deductible for falls within the Medicare-covered vision 
services benefit category. The Plan has followed Medicare rules by clearly disclosing in the contract that there 
is a $250 deductible which applies to Medicare-covered vision services excluding eyewear after cataract 
surgery. This cost sharing is a contractual obligation that had not been met at the time vision care was received 
on April 19, 2022. Therefore, we decided that the Plan does not have to waive the deductible for medical vision 
services (99204, 92250) provided on April 19, 2022.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ambulance services (A0425) provided on March 31, 
2022. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE has been 
exceeded. 
 
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code A0425 is 250. The MAI value for this code is 1. You billed 257 units of 
this code, exceeding the MUE. An appropriate modifier has not been used for payment of the additional units. 
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 ambulance services (A0425) provided on 
March 31, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services related to end-stage renal disease 
(ESRD) provided on February 7, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that the lab does not have a 
contractual agreement with the facility which indicates that these codes are included in the dialysis rate. The 
Plan denied your request. The Plan says Medicare does not separately pay for ESRD-related laboratory testing. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD laboratory services are not 
separately payable. Laboratories should bill the facility directly for laboratory services as they are considered 
part of the composite rate. No other payment for these services is allowed. Therefore, we decided that the Plan 
does not have to pay for the laboratory services related to end-stage renal disease (ESRD) provided on 
February 7, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the vision services provided on May 19, 2022. 
 
You asked the Plan to pay for the vision services. You say that you were told you could get your glasses from 
any provider and request reimbursement. The Plan denied your request. The Plan says vision services must be 
provided by a contracted provider. 
  Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers routine vision services when they are received from a contracted provider. 
 
We looked at the file and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the vision services have not been met. Specifically, the vision services were not received from a 
contracted provider. Therefore, we decided that the Plan does not have to pay for the vision services provided 
on May 19, 2022.