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

 
We decided that the Plan has to pre-approve a percutaneous implantation of neurostimulator electrode array, 
epidural (63650, L8680). 
 
You asked the Plan to pre-approve a percutaneous implantation of neurostimulator electrode array, epidural. 
You say that the enrollee has failed multiple injections and is in severe pain. The enrollee is not a candidate for 
surgery. The Plan denied your request. The Plan says that the requested procedure does not meet the 
requirements for approval. 
 
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item 
or service, then that item or service will be covered when it is 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 percutaneous implantation of 
neurostimulator electrode array, epidural. Our reviewer says that the requested items/services are considered 
medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic low 
back and neck pain. He has had physical therapy and chiropractic therapy. He has had epidural steroid 
injections, medial branch blocks, RFA of the medial branches as well as trigger point injections. The enrollee 
has had pain interventions over the past 15 years with little improvement. He has failed conservative therapy 
and surgical intervention is planned. The request meets the LCD and NCD criteria. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of percutaneous implantation of neurostimulator electrode array, epidural have 
been met. Therefore, we decided that the Plan has to pre-approve a percutaneous implantation of 
neurostimulator electrode array, epidural (63650, L8680).  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 25, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 provided on January 25, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient mental health services provided on February 15, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for outpatient mental health services. You say that you would like to request 
reconsideration of the denied claim. The Plan denied your request. The Plan says the provider is out-of-network 
and authorization is required prior to an out-of-network visit. 
 
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 outpatient mental health services provided on 
February 15, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided on March 28, 2022, by an out-
of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that you would like to request reconsideration of the 
denied claim. 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 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 laboratory services provided on March 28, 2022, 
by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on January 12, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that you would like this claim reprocessed based 
on the medical records. The Plan denied your request. The Plan says no separate payment will be made for the 
laboratory services. 
 
The Plan must follow Medicare rules. Medicare rules state that routine ESRD lab services are not separately 
payable. Labs should bill the facility directly for lab 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 provided on January 12, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the moderate sedation services (99152 and 99153) provided 
on February 2, 2022. 
 
You asked the Plan to pay for codes 99152 and 99153. You say that you would like the Plan to reconsider their 
denial of payment. The Plan denied your request. The Plan says the records do not support the services 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 99152 is Moderate sedation services provided by the 
same physician or other qualified health care professional performing the diagnostic or therapeutic service that 
the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of 
the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 
5 years or older. 
 
We find that CPT code 99152 is not supported in the medical record. Specifically, the medical record does not 
contain evidence that moderate sedation was performed with the presence of an independent trained observer. 
We have confirmed that code 99153 is an add-on code to code 99152. As the primary procedure code cannot be 
paid, code 99153 is also not payable. Based on this information, we decided that Medicare rules for coverage of 
codes 99152 and 99153 have not been met. Therefore, we decided that the Plan does not have to pay for the 
moderate sedation services (99152 and 99153) provided on February 2, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on August 2, 2021, billed with 
codes 81206, 81235, 81292, 81321, and 81301. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 
The Plan must follow Medicare rules. 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 
August 2, 2021, billed with codes 81206, 81235, 81292, 81321, and 81301.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided by an out-of-network provider 
on March 14, 2022. 
 
You asked the Plan to pay for laboratory services. You say that the specimen was shipped for testing, and you 
must process upon receipt of the test to expedite results. You say that the claim should be processed under the 
authorization of the referring provider and be appropriately paid. The Plan denied your request. The Plan says 
the services were not urgent or emergent and the services could have been rendered by a participating 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 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 laboratory services provided by an out-of-network 
provider on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic visit services provided on March 5, 
2022, by an out-of-network (OON) provider. 
 
You asked the Plan to pay for hospital outpatient clinic visit services. You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says the provider is out-of-network and 
authorization is required prior to an out-of-network visit. 
 
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 hospital outpatient clinic visit services provided on 
March 5, 2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83789 billed for date of service December 
10, 2021. 
 
You asked the Plan to pay for procedure code 83789. You say that the service was medically necessary. The 
Plan denied your request. The Plan says payment for code 83789 is bundled into payment for code 80307.  
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 83789 
is a column II code to column I code 80307. 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 83789 billed for date of service December 10, 
2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF services. 
  You asked the Plan to pre-approve SNF services. You say that you are requesting SNF services to access 
physical therapy to gain strength to use the new limb. The Plan denied your request. The Plan says your needs 
are custodial and can be met at a lower level of care. 
 
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 services. Our reviewer says that 
you do not qualify for SNF coverage. Our physician reviewer found that you do not have documented skilled 
nursing or skilled therapy needs. Your custodial and intermittent care needs can 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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve SNF services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve compression stockings identified with code A6530. 
 
You asked the Plan to pre-approve the compression stockings. You say that you are requesting a 
reconsideration of the Plan's denial. The Plan denied your request. The Plan says the item in this case is not a 
covered benefit under your contractual policy or by Medicare. 
 
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are 
noncovered because they do not meet the statutory definition of a surgical dressing.  
 
 
 Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for 
by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression 
stockings identified with code A6530.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the neuroplasty (64702) provided on December 16, 2021. 
  You asked the Plan to pay for the neuroplasty (64702). You say that 64702 can be unbundled. You say that the 
medical records should be reviewed, and payment made accordingly. The Plan denied your request. The Plan 
says this procedure is considered inclusive to CPT 26123. 
 
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 64702 is a column II code to column I code 26123; however, 64702 
was billed with a modifier.  
 
We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the 
Plan was correct in denying the request to pay for the neuroplasty (64702). Our reviewer says that the 
documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that 
the operative report describes a partial palmar fasciectomy and neuroplasty of left small finger. During a 
palmar fasciectomy, nerve impingement is assessed and treated when required. In this case, modifier -59 
cannot be supported as a distinct separate procedure from the primary procedure. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the neuroplasty (64702) have not been met. Therefore, we decided that the Plan 
does not have to pay for the neuroplasty (64702) provided on December 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Laparoscopy (47562) provided on January 18, 2022. 
 
You asked the Plan to pay for code 47562. You say that you would like the Plan to reconsider their denial of 
payment. The Plan denied your request. The Plan says the services are not covered as billed. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 47562 
is a column II code to column I code 47600 with a modifier indicator of 0. The column II code is therefore 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 the Laparoscopy (47562) provided on January 18, 2022.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF). 
 
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. 
The Plan says rules for SNF care have not been met. 
 
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 medically reasonable and necessary. Our physician reviewer found that you do not 
qualify for SNF coverage. You do not have documented skilled nursing needs.  You do not have documented 
skilled therapy needs. The records shows that you are currently ambulating more than 100 feet and tending to 
activities of daily living with minimal supervision. Daily skilled services are not required to establish a 
maintenance program or to prevent deterioration of your condition. Your care needs, custodial and intermittent, 
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 admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on January 5, 2021, billed with 
codes 81406, 81406-59, 81405, 81405-59, 81404, 81404-59, 81403, 81403-59, 81402, 81401, 81401-59, 
81400, 81321, 81314, 81311, 81310, 81309, 81301, 81293, 81276, 81275, 81272, 81270, 81235, 81210, 81201, 
81173, 81121, and 81120. 
 
You asked the Plan to pay for the genetic testing billed. You say that you would like this claim reprocessed and 
approved for payment. The Plan denied your request. The Plan says this claim has not been billed 
appropriately. 
 
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 5, 2021, billed with codes 81406, 81406-59, 81405, 81405-59, 81404, 81404-59, 81403, 81403-59, 
81402, 81401, 81401-59, 81400, 81321, 81314, 81311, 81310, 81309, 81301, 81293, 81276, 81275, 81272, 
81270, 81235, 81210, 81201, 81173, 81121, and 81120.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for domiciliary services provided on February 16, 2022, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for domiciliary services. You say that you would like to request reconsideration of 
the denied claim. 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 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 domiciliary services provided on February 16, 
2022, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on December 3, 2021 billed with 
codes 81479. 
 
You asked the Plan to pay for the genetic testing billed. You say that the services were medically necessary. 
The Plan denied your request. The Plan says the claim cannot be paid as billed. 
 
The Plan must follow Medicare rules. The rules say that 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 
December 3, 2021 billed with codes 81479.