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

 
We decided that the Plan does not have to pay for the subsequent hospital care rendered on August 25, 2021. 
 
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 services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 99233 (subsequent hospital care) and 99239 (hospital 
discharge day management). Code 99233 is a column II code with a modifier indicator of 1 when billed with 
column I code 99239. Code 99233 was not billed with an appropriate modifier to allow for separate payment. 
Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered on August 
25, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on November 11, 2020. 
 
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 services were not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on November 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the comprehensive pharmacogenetics gene panel provided on 
August 16, 2021. 
 
You asked the Plan to pay for the testing services. The Plan denied your request. The Plan says one code must 
be submitted for the panel. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We looked at the file and the rules. The claim shows that the gene panel was billed with multiple codes. If a 
single procedure is performed, only one code with one unit of service may be reported for the procedure. Based 
on this information, we decided that Medicare rules for coverage of the testing services have not been met. 
Therefore, we decided that the Plan does not have to pay for the comprehensive pharmacogenetics gene panel 
provided on August 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for an established patient office or other outpatient visit provided 
on November 9, 2021. 
 
You asked the Plan to pay for an established patient office or other outpatient visit. You say that you fell down  
Your basement steps and you were in bed for a week before deciding that you needed treatment to free up your 
frozen back. You say that you used your Plan member materials as a reference that say that chiropractor 
services are covered. The Plan denied your request. The Plan says an office visit is not a covered services when 
billed by a chiropractor. 
 
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is 
manual manipulation of the spine to correct a subluxation.  
 
We looked at the file and Medicare rules. The file shows that manual manipulation of the spine to correct a 
subluxation was not billed to the Plan. Therefore, we decided that the Plan does not have to pay for an 
established patient office or other outpatient visit provided on November 9, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for CT scan, head or brain; without contrast material (CPT code 
70450) provided on November 29, 2021. 
 
You asked the Plan to pay for the CT scan. You say that the claim should be paid. The Plan denied your 
request. The Plan says the service is 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 70496 
is a column II code to column I code 70450. 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 CT scan, head or brain; without contrast material (CPT code 
70450) provided on November 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for anesthesia for upper endoscopic procedures (00732) 
provided on July 28, 2021. 
 
You asked the Plan to pay for the anesthesia for upper endoscopic procedures (00732). You say that the claim 
was billed with the appropriate modifier payable under CMS guidelines and the claim should be processed for 
payment. The Plan denied your request. The Plan says the claim denied as it was billed with an incorrect place 
of service. 
  The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare 
Physician Fee Schedule, the Place of service (POS) code is generally used to reflect the actual setting where the 
beneficiary receives the face-to-face service. 
 
In this case, the CPT Code Manual definition of code 00732 is anesthesia for upper gastrointestinal endoscopic 
procedures, endoscope introduced proximal to duodenum; endoscopic retrograde cholangiopancreatography 
(ERCP). 
 
We find that CPT code 00732 is not supported in the medical record. Specifically, the records show the 
enrollee was an inpatient at the time the service was received but an outpatient POS was billed. Based on this 
information, we decided that Medicare rules for coverage of the anesthesia for upper endoscopic procedures 
(00732) have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for upper 
endoscopic procedures (00732) provided on July 28, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the services (CPT code(s): 38720-59, 60240-59, 64716-59) 
provided on June 1, 2021. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says the services are not supported by the records. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We 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 services. Our reviewer found CPT 38720 - 
Documentation submitted was reviewed and does not meet criteria.  Operative report does not describe a 
complete cervical lymphadenectomy.  To cite the report "Several of these lymph nodes around that 
retromandibular vein were microdissected and removed with the lateral neck dissection specimen. The nodes in 
2A and some of 5A were removed using electrocautery and passed below the spinal accessory nerve, which stimulated well with a nerve monitor. An enlarged level 2A deep-seated posterolateral node that was adherent 
to the posterolateral aspect of the internal jugular vein in this level was noted. We turned our attention away 
from that portion of the neck and to the posterior extent of dissection down to the level of the cervical rootlets".  
CPT 38720 cannot be verified as performed.   
 
CPT 60240 - Documentation submitted was reviewed and does not meet criteria. The documentation does not 
support modifier 59, as a modified radical neck dissection was performed, which would include a 
thyroidectomy.  Technical hints and potential pitfalls in modified radical neck dissection for thyroid cancer - 
PMC (nih.gov). 
 
CPT 64716 - Documentation submitted was reviewed and does not meet criteria. Operative report does not 
support this procedure as an independent procedure.  Operative report describes laryngeal nerve was stimulated 
and dissected out and preserved.  This procedure would not be an independent 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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for the services (CPT code(s): 38720-59, 60240-59, 64716-59) provided on June 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the alveoloplasty (D7310), extraction (D7140), and hospital 
call (D9420), provided on May 19, 2021. 
 
You asked the Plan to pay for the dental services. You say that the services should be covered. The Plan denied 
your request. The Plan says these are not covered services. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the 
alveoloplasty (D7310), extraction (D7140), and hospital call (D9420), provided on May 19, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the drug testing rendered on April 7, 2021. 
 
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 services are not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the drug testing rendered on April 7, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (82310, 82728, 83550, 83540, 84100) 
provided on May 10, 2021. 
 
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because 
there is not a contract to state that these services are included in the ESRD facility rate. The Plan denied your 
request. The Plan says the provider reported routine lab services related to the treatment of end stage renal 
disease (ESRD), which does not follow industry standard coding rules. 
 
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 (82310, 82728, 83550, 83540, 84100) provided on May 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cochlear ear programming provided on November 11, 
2021. 
 
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the service is 
not a covered benefit. 
 Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that 
exceeds Medicare coverage. For that reason, the plans coverage rules apply in this case.  
 
We looked at the file, and the Plan's rules. The diagnostic analysis provided is not a covered benefit under the 
enrollees plan. Based on this information, we decided that the rules for coverage have not been met. Therefore, 
we decided that the Plan does not have to pay for the cochlear ear programming provided on November 11, 
2021.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pay for additional imaging services provided to the enrollee on October 19, 
2021. 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says that there is no additional documentation supporting additional studies which were billed and 
remain denied. 
 
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 73721 is "Magnetic resonance (eg, proton) imaging (MRI), any joint of lower extremity; without contrast 
material." 
 
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 services. Our reviewer says that the services at issue in 
this case were supported by the medical records. Our reviewer found the enrollee had bilateral knee MRI 
exams on 10/19/21, which are documented with separate reports and read at different times. Two separate 
exams should be reimbursed. 
 
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 services have been met. Therefore, we decided that the Plan has to pay for 
additional imaging services provided to the enrollee on October 19, 2021.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pentamidine isethionate rendered on May 24, 2021. 
 
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 services are not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that the OPPS status indicator identifies whether the 
service described by the HCPCS code is paid under the OPPS and if so, whether payment is made separately or 
packaged.  
 
We looked at the file and Medicare rules. Billed procedure code J2545 has an OPPS status indicator of B and 
no separate payment. Therefore, we decided that the Plan does not have to pay for the pentamidine isethionate 
rendered on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the injection services provided on December 27, 2021. 
 
You asked the Plan to pay for the injection services. You say that the provider did not provide the services they 
billed. The Plan denied your request. The Plan says the claim has been upheld as a duplicate of paid a claim. 
 
The Plan must follow Medicare rules. We looked at the file and Medicare rules. This claim is denied for being 
a duplicate of another paid claim. Based on this information, we decided that Medicare rules for coverage of 
the injection services have not been met. Therefore, we decided that the Plan does not have to pay for the 
injection services provided on December 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for psychotherapy services provided from  
August 27, 2021, through October 4, 2021. 
 
You asked the Plan to reimburse you for psychotherapy services. You say that this provider's professional 
experience in providing a wide range of emotional and behavior services has been helpful and provided you 
with personal growth. The Plan denied your request. The Plan says this provider is ineligible to participate in 
Medicare and is not contracted with the Plan. 
 
The Plan must follow Medicare rules. Medicare rules say that a Marriage Family Therapist (MFT) is not 
eligible to participate in the Medicare program. 
 
We looked at the file and Medicare rules. The provider at issue in this case is a Marriage Family Therapist 
(MFT). Medicare says that a Marriage Family Therapist (MFT) is not eligible to participate in the Medicare 
program. Therefore, we decided that the Plan does not have to reimburse you for psychotherapy services 
provided from August 27, 2021, through October 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for additional imaging services provided to the enrollee on 
October 15, 2021. 
 
 
You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. 
The Plan says Current Procedural Terminology (CPT) code 76497-26 (1 unit) remains 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 76497 is "Unlisted computed tomography procedure (eg, 
diagnostic, interventional)." 
 
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 services. Our reviewer says that the services at issue in 
this case were not supported by the medical records. Our reviewer found there is a report of computed 
tomography (CT) scan of the soft tissue of the neck dated 10/25/21 in the records. As such, the plan's denial is 
correct. The appropriate code for reimbursement would be CPT 70492, and not CPT 76497.  
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 services have not been met. Therefore, we decided that the Plan does not 
have to pay for additional imaging services provided to the enrollee on October 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on July 8, 2020. 
 
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 services are not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that lab services, the POS code must reflect the 
location in which the sample was taken. POS code 81 is used to describe samples taken by the laboratory 
directly. 
 We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of these services have not been met. Specifically, this claim was billed with the laboratory POS code. 
The records do not support that the sample was taken in a laboratory setting. Therefore, we decided that the 
Plan does not have to pay for the laboratory services rendered on July 8, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the PCD (CPT code E0675) and the segmental gradient 
pressure pneumatic appliance (CPT code E0673) provided on September 1, 2021. 
 
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. 
The Plan says the DME is not covered.  
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, the PCD is not covered by Medicare to prevent deep vein 
thrombosis during and/or following surgery. Medicare rules say that CMS does not pay any provider or 
supplier other than the facility or hospital for services furnished to the beneficiary while an inpatient. The 
facility or hospital must furnish all necessary covered services to the beneficiary either directly or under 
arrangements made between the facility and hospital and outside providers. The enrollee used the equipment in 
the facility during and/or after surgery. Payment for this service would have been included under the facility 
claim. Payment for this service is the responsibility of the facility or hospital that provided the surgery. 
Therefore, we decided that the Plan does not have to pay for the PCD (CPT code E0675) and the segmental 
gradient pressure pneumatic appliance (CPT code E0673) provided on September 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the medical records provided will show 
proof of medical necessity. The Plan denied your request. The Plan says the enrollee does not have clinical 
conditions that cannot be appropriately treated in the current hospital and there are no issues for which an 
LTACH may offer a therapeutic advantage. 
 
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically 
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 
 
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 the LTACH services. Our reviewer says 
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is currently undergoing treatment at an ACH for COVID-19. The 
enrollee was intubated/ventilated multiple times. The enrollee eventually received a tracheotomy and a feeding 
tube. The enrollee is being managed by multiple specialists and therapists.  There is no evidence that the 
enrollee requires services that are not currently available. As LTACHs and ACHs are licensed to provide the 
same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged 
to a lower level of care for any ongoing LTC needs. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve long term acute care hospital (LTACH) services.