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

 
We decided that the Plan does not have to pay for procedure codes U0004 and U0005 billed for date of service 
January 3, 2022. 
 
You asked the Plan to pay for procedure codes U0004 and U0005. You say that these tests should be 
reimbursed. The Plan denied your request. The Plan says payment for code U0004 is bundled into payment for 
code U0001. 
 
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 U0004 is a column II code to column I code U0001 with a modifier 
indicator of 0. The column II code is therefore not payable. As U0005 is an add-on code, it cannot be paid since 
U0004 is not payable. 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 U0004 and U0005 billed for date of service 
January 3, 2022.
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 records provided support the need for IRF care. 
The Plan denied your request. The Plan says this request does not meet Medicare guidelines for medical 
necessity because the enrollee's medical condition requires further evaluation and treatment in the acute care 
hospital. 
 
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 enrollee is not medically stable but improving with persistent abscesses and does 
not need a physical medicine and rehabilitation physician's close supervision 3 times per week (at a minimum) 
for the ongoing management of any active or acute exacerbations of chronic medical conditions. there were no 
rehabilitation nursing needs identified or documented. At the current functional level, the enrollee does not 
need 3 hours a day x 5 days a week of therapies with multidisciplinary approach in an IRF. Document does not 
support functional necessity for admission to an IRF. The enrollee has current medical complexity but no acute 
rehabilitation nursing needs and is at high functional level for IRF. While the enrollee would benefit from 
physical therapy and occupational therapy, his rehabilitation needs can be safely met in an alternate and low 
intensity setting such as in-home with services once medical/surgical issues are stable. 
 
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 outpatient surgical procedure and related services 
provided from February 18, 2022, through February 19, 2022. 
 
You asked the Plan to pay for the outpatient hospital services. You say that this was medically necessary and 
should be paid as billed. The Plan denied your request. The Plan says this outpatient claim cannot be paid as 
the surgery performed is an inpatient-only procedure. 
 
The Plan must follow Medicare rules. The rules say that there is no payment under the OPPS for services that 
CMS designates to be inpatient-only services. These services have an OPPS status indicator of C in the 
OPPS Addendum B and are listed together in Addendum E of each years OPPS/ASC final rule. 
 
We looked at the file and Medicare rules. The procedure code 56630 is an inpatient-only procedure. This 
cannot be reimbursed on an outpatient claim. Based on this information, we decided that Medicare rules for 
coverage of the outpatient hospital services have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient surgical procedure and related services provided from February 18, 2022, 
through February 19, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for codes 36478 and 36479 provided on November 4, 2021. 
 
You asked the Plan to pay for codes 36478 and 36479. 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. 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 36478 is endovenous ablation therapy of incompetent 
vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; first vein treated. 
 
The CPT Code Manual definition of code 36479 is endovenous ablation therapy of incompetent vein, 
extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in 
a single extremity, each through separate access sites (List separately in addition to code for primary 
procedure). 
 
 
 We find that CPT codes 36478 and 36479 are not supported in the medical record. Specifically, these codes 
were appended with modifier 79 and LT. A 0, 10 or 90-day post-operative procedure was not reported or found 
during its applicable post-operative period. Modifier 79 is used to indicate that the performance of a procedure 
or service during the post-operative period was unrelated to the original procedure. The unrelated procedure 
must be reported during the post-operative period of the original service. Since the original procedure or 
service has not been identified, the line appended with modifier 79 has been denied. Although codes 36478 and 
36479 were reported with RT modifier for date of service October 26, 2021, these services have a zero-day 
global period. This means these services are not payable as billed. Based on this information, we decided that 
Medicare rules for coverage of codes 36478 and 36479 have not been met. Therefore, we decided that the Plan 
does not have to pay for codes 36478 and 36479 provided on November 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve femtosecond laser with limbal relaxing incisions 
(A9270) and multifocal and toric lens (V2787). 
 
You asked the Plan to pre-approve femtosecond laser with limbal relaxing incisions and multifocal and toric 
lens. You say that the services are necessary. The Plan denied your request. The Plan says the requested 
services are non-covered. 
 
The Plan must follow Medicare rules. Medicare rules say that medically necessary services are those that are 
reasonable and necessary for the diagnosis or treatment of an illness or injury. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of femtosecond laser with limbal relaxing incisions and multifocal and toric lens have not been met. Therefore, we decided that the Plan does not have to pre-approve femtosecond laser with limbal relaxing 
incisions (A9270) and multifocal and toric lens (V2787).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator. 
 
You asked the Plan to pre-approve a home ventilator. You say that the requested device is needed for life-
sustaining measures, and any device that does not include alarms and battery backup is not sufficient. The Plan 
denied your request. The Plan says the requested home ventilator will be set in intelligent volume-assured 
pressure support (iVAPS) mode with Auto expiratory positive airway pressure (EPAP) that could be delivered 
by bilevel positive airway pressure (BiPAP) and is therefore not covered. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 home ventilator. Our reviewer says 
that the criteria for coverage have not been met. Our physician reviewer found a home ventilator is not 
medically necessary.  The enrollee has obesity-hypoventilation syndrome, obstructive sleep apnea (OSA), and heart failure with reduced ejection fraction (HFrEF.)  The enrollee was recently hospitalized with chronic heart 
failure (CHF), due in part to inconsistent use of diuretic.  Arterial Blood Gasses (ABGs) were consistent with 
acute on chronic hypercarbic respiratory failure. There is no diagnosis of chronic obstructive pulmonary 
disease (COPD), thoracic restrictive disease, or neuromuscular disease. This enrollee may benefit from BiPAP 
during sleep.  This has not been tried and shown to fail as an outpatient, when CHF is adequately treated.  
Medicare does not cover a home ventilator when used as BiPAP, or for the treatment of OHS. 
 
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 home ventilator have not been met. Therefore, we decided that the Plan does 
not have to pre-approve a home ventilator.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar 
spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine.. 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. Medicare rules say that MRIs are covered only when they are medically 
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 an MRI of the lumbar spine. Our 
reviewer says that the services are not medically necessary. Our physician reviewer found during your last 
encounter with a vascular specialist on October 21, 2022 the plan was for MRI of the cervical spine. There is 
no mention of lower extremity weakness or lower extremity radicular symptoms. Bilateral lower extremity 
doppler on October 21, 2022 showed mild stenosis of both lower extremities. There were no symptoms or 
physical findings related to the lumbar spine. Absent such information the medical necessity of MRI lumbar 
spine has not been established in the records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an MRI of the lumbar spine have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Jardiance. 
 
You asked the Plan to pre-approve Jardiance. You say that the medication is necessary. The Plan denied your 
request. The Plan says the enrollee's plan does not have a Medicare Part D benefit, or a separate pharmacy 
benefit managed by the plan, therefore self-administered drugs do not meet the criteria for coverage. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Jardiance.  
 
Benefits for Jardiance may be available under Medicare Part D. Contact the Plan that administers Part D 
benefits for further information concerning any benefits and appeal rights.
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 May 11, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that these are payable codes and 
represent medically necessary testing. 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 May 11, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure codes 88341, 88342, 88360, and 88377 billed for 
date of service February 15, 2022. 
 You asked the Plan to pay for procedure codes 88341, 88342, 88360, and 88377. You say that you disagree 
with the Plan's denial. The Plan denied your request. The Plan says these codes are included in the facility 
payment and are not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Technical components must be billed by the facility where the enrollee was an inpatient or outpatient and are 
not separately payable to the lab. 
 
The records indicate that the specimen was taken while the enrollee was an inpatient or outpatient. Per the 
Physician Fee Schedule, there is a Professional/Technical indicator of 1 for CPT codes 88341, 88342, 88360, 
and 88377. This means there is both a professional and technical component for the CPT codes. In this case, an 
appropriate modifier to indicate the professional component has not been billed with CPT codes 88341, 88342, 
88360, and 88377. Based on this information, we decided that Medicare rules for coverage of procedure code 
88341, 88342, 88360, and 88377 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure codes 88341, 88342, 88360, and 88377 billed for date of service February 15, 2022.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve additional routine transportation trips.
You asked the Plan to pre-approve additional routine transportation trips. You say that you have upcoming dialysis appointments three times per week with your doctor and need additional trips for your transportation. The Plan denied your request. The Plan says that the requested trips exceed your routine transportation benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of sixty (60) trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided that you have exhausted the Plan maximum benefit for coverage of routine transportation. Therefore, we decided that the Plan does not have to pre-approve additional routine transportation trips.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) provided on
February 21, 2022.
You asked the Plan to pay for the dental services. You say that the dentist did not check your tooth history. The
Plan denied your request. The Plan says your benefit for the requested item or service 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 Plan's 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 requested item or service was exhausted on date of service January 4, 2022.
Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150)
provided on February 21, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay more for the dental services provided on September 2, 2021.
You asked the Plan to pay more for the dental services. You say that you found the provider on the plan's
website to be in-network. The Plan denied your request. The Plan says you are responsible for any charged
amount above the Plan's cost-sharing amount when your services are received from an out-of-network
provider.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
You have been asked to pay the difference between the out-of-network provider's charges and the Plan's
payment. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan.
The Plan has provided documentation confirming the provider was out-of-network at the time these services
were received. Therefore, we decided that the Plan does not have to pay more for the dental services provided
on September 2, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluations (D0140), the intraoral-periapical first radiographic images (D0220), and the pulp vitality test (D0460) provided from February 2, 2022, and February 24, 2022.
You asked the Plan to pay for the dental services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says that the limited oral evaluations and the periapical radiographic images provided exceed the allowable frequency benefit for these services. Additionally, the pulp vitality test is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's 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 limited oral evaluations and the intraoral-periapical first radiographic images was exhausted on date of service December 30, 2021. The pulp vitality test is not a covered benefit under your contractual policy. Therefore, we decided that the Plan does not have to pay for the limited oral evaluations (D0140), the intraoral-periapical first radiographic images (D0220), and the pulp vitality test (D0460) provided from February 2, 2022, and February 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with multiple power options (K0861) with power recline and attachments.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says that the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. Our Medical director looked at the case file and the reopen request. At issue is coverage for a Group 3 power wheelchair with multiple power options with power recline and attachments. Our Medical Director states that the available clinical documentation in the case file does not support that you meet criteria for a Group 3 power wheelchair with multiple power options with power recline and attachments. Our physician reviewer found that your condition does not meet Medicare criteria for these services. We looked at this physician's review, the file, and Medicare rules. 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 pre-approve a Group 3 power wheelchair with multiple power options (K0861) with power recline and attachments.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused oral evaluation (D0140) and an intraoral periapical first radiographic image (D0220) provided on February 3, 2022.
You asked the Plan to pay for the dental services. The Plan denied your request. The Plan says your benefit for the requested item or service 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 Plan's 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 problem focused oral evaluation was exhausted on date of service January 21, 2022, and the periapical X-ray was exhausted on February 26, 2021.
Therefore, we decided that the Plan does not have to pay for the problem focused oral evaluation (D0140) and an intraoral periapical first radiographic image (D0220) provided on February 3, 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 June 9, 2022. 
 
You asked the Plan to pay for the ESRD-related laboratory services. You say that you disagree with the Plan's 
denial. 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 June 9, 
2022.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for procedure code 70551 provided on May 6, 2022. 
 
You asked the Plan to pay for procedure code 70551. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says that they were unable to make a determination 
within the allotted time frame. 
 
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. In this case, the Plan has not provided enough evidence to support the denial of 
payment for these services based on Medicare criteria. Therefore, we decided that the Plan has to pay for 
procedure code 70551 provided on May 6, 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.