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

 
We decided that the Plan does not have to pay for the assay of magnesium (83735) provided on June 28, 2021. 
 
You asked the Plan to pay for the assay of magnesium. You say that the provider didn't provide the correct 
diagnosis in time. The Plan denied your request. The Plan says this claim was not filed timely. 
 
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, 
must be filed no later than one calendar year after the date of service. 
 
The record shows that a claim for the assay of magnesium was not filed until November 4, 2022. This means 
that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we 
decided that the Plan does not have to pay for the assay of magnesium (83735) provided on June 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the total electric hospital bed with mattress 
(E0265), handling and/or conveyance of device when created by an outside laboratory or specialty service (99002), trapeze bar (E0910), and miscellaneous durable medical equipment (E1399) provided on September 
14, 2022. 
 
You asked the Plan to reimburse you for the hospital bed and accessories. You say that the supplier did not 
have an adequate bed for what you needed. You say that you had to order online as a result. The Plan denied 
your request. The Plan says the items in this case are not covered by Medicare or the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.  
 
While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers 
coverage for this item. Therefore, we decided that the Plan does not have to reimburse you for the total electric 
hospital bed with mattress (E0265), handling and/or conveyance of device when created by an outside 
laboratory or specialty service (99002), trapeze bar (E0910), and miscellaneous durable medical equipment 
(E1399) provided on September 14, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for psychotherapy provided on from June 27, 2022, to 
September 12, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the psychotherapy. You say that you had referrals from your primary physician 
to see this provider. The Plan denied your request. 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 services were not referred by a network provider or rendered in an in-network facility. The Plan says that 
the Plan has determined that these services are not urgent or emergent, nor were they approved in advance. 
 
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 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 psychotherapy provided on from June 27, 2022, to  
September 12, 2022, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a FreeStyle Libre Kit 2 continuous glucose monitor 
(CGM). 
 
You asked the Plan to pre-approve a FreeStyle Libre CGM. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested device. 
 
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically 
reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, 
require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an 
in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment 
plan. 
 
 We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin 
with at least three daily injections or require frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of a FreeStyle 
Libre CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a FreeStyle 
Libre Kit 2 continuous glucose monitor (CGM).
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76705-26 billed for date of service 
September 7, 2022. 
 You asked the Plan to pay for procedure code 76705-26. You say that the claim is billed correctly and should 
be paid The Plan denied your request. The Plan says payment for code 76705-26 is bundled into payment for 
code 93976-26. 
 
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 
76705-26 is a column II code to column I code 93976-26. 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 76705-26 billed for date of service 
September 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the fungal infection PCR panel (87481, 87798) provided on 
December 9, 2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for the laboratory services. You say that please see attached medical records for 
review and reconsideration. The Plan denied your request. The Plan says enrollee's must receive their care from 
an in-network provider. Non-participating providers must obtain prior authorizations prior to providing 
treatment. 
 
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 items/services at issue in this appeal. The Plan did not pre-approve the 
item/service at issue. We found no exception that would require the Plan to pay for these items/services. 
Therefore, we decided that the Plan does not have to pay for the fungal infection PCR panel (87481, 87798) 
provided on December 9, 2022, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve custom shoe supports from an out-of-network provider 
to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve custom shoe supports from an out-of-network provider. You say that you 
would like to request reconsideration of the denied authorization. The Plan denied your request. The Plan says 
the provider is out-of-network, and it was determined these services can be received in-network. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
custom shoe supports from an out-of-network provider to be provided by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76641 billed for date of service December 5, 
2022. 
 
You asked the Plan to pay for procedure code 76641. You say that this claim denied as a duplicate in error. The 
Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. 
 The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service 
exceeds the MUE value for the HCPCS/CPT code will be denied. 
 
In this case, the MUE for CPT code 76641 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Specifically, you billed one line item of this code with the LT modifier and one line 
item of this code with the RT modifier instead of billing one line item with the bilateral modifier as is required. 
Based on this information, we decided that Medicare rules for coverage of procedure code 76641 have not been 
met. Therefore, we decided that the Plan does not have to pay for procedure code 76641 billed for date of 
service December 5, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that a lower level of care is not safe, sufficient or 
equipped to address the enrollee's needs related to their comorbidities and allow them to regain their prior level 
of functioning. Any lower level of care or delay in review will place the enrollee at a higher risk for further 
decompensation. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria 
for admission to an IRF. There is no evidence that care cannot be met at a lower level of care. Skilled therapies 
at home or at a skilled nursing facility may be approved upon request. 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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 IRF admission and services.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for extra ambulance mileage provided on August 5, 2022. 
 
You asked the Plan to pay for ambulance mileage. You say that you needed to be closer to your home, family, 
and friends for your recovery. The Plan denied your request. The Plan says ambulance mileage beyond the 
distance to the nearest appropriate facility is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that ambulance miles beyond the closest available 
facility are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of ambulance mileage have not been met. Therefore, we decided that the Plan does not have to pay 
for extra ambulance mileage provided on August 5, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0651) and segmental 
pneumatic appliance (E0667) to be provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve a pneumatic compression device and appliance. You say that the enrollee 
has been suffering from lymphedema for years and it is affecting their daily life. The Plan denied your request. 
The Plan says enrollee's must receive care their medical care from an in-network provider. 
 
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 pre-approve care from out-of-network providers only in cases involving 
emergencies, out of area urgent care and care that cannot be provided by network providers. 
 
The requested provider in this case is not a network provider with the Plan. The Plan has network providers 
available who can provide the items/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
a pneumatic compression device (E0651) and segmental pneumatic appliance (E0667) to be provided by an 
out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Neupogen 480MCG/0.8ML prefilled syringe (J1442). 
 
You asked the Plan to pre-approve the medication. You say that the medication is medically necessary. The 
Plan denied your request. The Plan says Neupogen is a self-administered drug and does not fall under Part B 
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 Neupogen 480MCG/0.8ML 
prefilled syringe (J1442).  
 Benefits for the medication 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 DecisionDx-SCC testing provided on September 15, 
2022. 
 
You asked the Plan to pay for the DecisionDx-SCC testing. You say that this service was medically necessary. 
The Plan denied your request. The Plan says the claim for this molecular pathology testing did not include the 
required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange.  
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. Based on this information, we decided that Medicare rules for coverage of the DecisionDx-SCC 
testing have not been met. Therefore, we decided that the Plan does not have to pay for the DecisionDx-SCC 
testing provided on September 15, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an office visit provided on January 24, 2022. 
 
You asked the Plan to pay for the office visit. You say that  The Plan denied your request. The Plan says there 
was no worker's compensation carrier denial provided. 
 
The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers 
when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for 
services until the claim for those services has gone to the primary insurer. However, plans are still required to 
coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers 
in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can 
direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a 
bill for reimbursement to the primary insurer.  
The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has not received 
a denial from the workers compensation carrier. As the secondary insurer, the Plan cannot be held responsible 
for the office visit until the primary insurer has denied the claim for these services. Therefore, we decided that 
the Plan does not have to pay for an office visit provided on January 24, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652) and segmental 
pneumatic appliance (E0656, E0667). 
 
You asked the Plan to pre-approve a pneumatic compression device and appliances. You say that the enrollee is 
unable to tolerate compression which means that the enrollee will not be able to tolerate the sustained high-
pressure squeeze and hold technique of a basic pump. The Plan denied your request. The Plan says the enrollee 
does not meet the Medicare criteria as the records do not show that there has been a four-week trial of E0650 or 
E0651. 
 
The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of 
lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy 
demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, 
multiple-hour home usage of the E0650 or E0651 is required. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least 
four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, 
training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance 
provided. Therefore, we decided that the Plan does not have to pre-approve a pneumatic compression device 
(E0652) and segmental pneumatic appliance (E0656, E0667).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunohistochemistry or immunocytochemistry (88342) 
provided on June 14, 2022. 
 
You asked the Plan to pay for immunohistochemistry or immunocytochemistry. You say that this claim should 
be paid. The Plan denied your request. The Plan says the procedure has been billed and allowed the maximum 
number of times allowed by our payment policy. 
 
The Plan must follow Medicare rules. Medicare rules say that when services or supplies are rendered by a non- 
contracting, original Medicare, participating provider, there is no balance billing paid by either the Plan or the 
enrollee. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of laboratory services have not been met. Specifically, the record indicates that the Plan has paid the 
Medicare allowed amount for this service. A Medicare provider should accept the Medicare allowed amount as 
payment in full. In this case, the Plan is not responsible for paying the balance that remains after the Medicare 
allowed payment. Therefore, we decided that the Plan does not have to pay for immunohistochemistry or 
immunocytochemistry (88342) provided on June 14, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve a continued stay at a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve a continued stay at a SNF. You say that the SNF care is medically 
necessary. The Plan denied your request. The Plan says that the enrollee's benefit period has been exhausted. 
 
The Plan must follow Medicare rules. The Plan's rules say that enrollees are covered for up to 120 days of 
skilled care in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level 
of care and ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.  
 
We looked at the file, Medicare rules, and the Plan's rules. Documentation provided show the date of discharge 
for the prior SNF care was November 16, 2022, and the admission date of the current SNF care was March 2, 
2023, which is more than the required 60 days for a new benefit period to begin. Based on this information, we 
decided that Medicare and Plans rules for coverage of a continued stay at a SNF have been met. Therefore, we 
decided that the Plan has to pre-approve a continued stay at a skilled nursing facility (SNF).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99239 provided on June 10, 2022. 
 
You asked the Plan to pay for procedure code 99239. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing 
of code 99239. 
 
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 99239 is Hospital discharge day management; more than 
30 minutes. 
 
We find that CPT code 99239 is not supported in the medical record. Specifically, code 99239 is a time-based 
code. In order to bill CPT 99239, the documentation must note that more than thirty minutes was spent 
providing services to the enrollee on the day of discharge. The progress note for June 10, 2022, does not note 
how much time was spent providing services to the enrollee. As such, the provided documentation does not 
support the billing of code 99239. Based on this information, we decided that Medicare rules for coverage of procedure code 99239 have not been met. Therefore, we decided that the Plan does not have to pay for 
procedure code 99239 provided on June 10, 2022.