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

 
We decided that the Plan does not have to pay for procedure code(s) 88360 billed for date of service January 
25, 2022. 
 
You asked the Plan to pay for procedure code(s) 88360. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says this code is included in the facility 
payment and is 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 code(s) 88360. This means 
there is both a professional and technical component for the CPT code(s). In this case, an appropriate modifier 
to indicate the professional component has not been billed with CPT code(s) 88360. Based on this information, 
we decided that Medicare rules for coverage of procedure code 88360 have not been met. Therefore, we 
decided that the Plan does not have to pay for procedure code(s) 88360 billed for date of service January 25, 
2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services rendered from July 6, 2022, to July 
8, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the NOA was not received timely. As such, this final claim was correctly denied. 
 The Plan follows Medicare rules. The rules say that an NOA must be submitted within 5 days of the start of 
care date for home health services. NOAs which are received more than 30 days from the timely filing date 
result in no payment being made for the episode of care.  
 
In this case, the start of care date is July 6, 2022. The NOA was not received by the Plan until March 23, 2017. 
As more than 30 days passed between the timely filing date and the NOA receipt, no payment can be made on 
this claim. Therefore, we decided that the Plan does not have to pay for the home health services rendered from 
July 6, 2022, to July 8, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for intraoral-periapical x-rays each additional radiographic 
image (D0230), 2D oral/facial photographic images (D0350), oral hygiene instructions (D1330), localized 
delivery of antimicrobial agents into diseased crevicular tissue (D4381), and core buildup, including any pins 
when required (D2950) provided on August 12, 2022, to August 24, 2022. 
 
 
 
 
 You asked the Plan to pay for the dental services. You say that you get $2,000.00 for necessary dental work 
and procedures and the Plan has not paid that to you yet. The Plan denied your request. The Plan says there is 
no coverage for 2D oral/facial photographic images (D0350), oral hygiene instructions (D1330), localized 
delivery of antimicrobial agents into diseased crevicular tissue (D4381), and core buildup, including any pins 
when required (D2950). The Plan also says an intraoral-periapical x-ray each additional radiographic image 
(D0230) is allowed one procedure code per calendar year at 100% by an in-network provider. 
 
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, certain limitations apply. The record 
shows the benefit for the intraoral-periapical each additional radiographic image (D0230) was exhausted on 
August 12, 2022 when the Plan covered the intraoral-periapical first radiographic image. The remaining items 
or services requested are not among those covered under this benefit.  Therefore, we decided that the Plan does 
not have to pay for intraoral-periapical x-rays each additional radiographic image (D0230), 2D oral/facial 
photographic images (D0350), oral hygiene instructions (D1330), localized delivery of antimicrobial agents 
into diseased crevicular tissue (D4381), and core buildup, including any pins when required (D2950) provided 
on August 12, 2022, to August 24, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued acute inpatient psychiatric hospital care. 
 
You asked the Plan to pre-approve these services. You say that the requested services are medically necessary 
for the enrollee. The Plan denied your request. The Plan says these services are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the 
patient requires active treatment.  
 
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 these services. Our reviewer says that 
the requested services are not medically necessary.  Our physician reviewer found that the enrollee was involuntarily admitted to the state facility for acute 
inpatient psychiatric hospitalization on September 28, 2022 with Unspecified Psychotic Disorder, 
Methamphetamine Use Disorder, and Alcohol Use Disorder. Based upon the review of the records provided, it 
was not expected that this enrollee would improve in a reasonable period of time as he did not have 
dangerousness to self or others, auditory hallucinations, or delusions and was not showing any behavioral 
issues. This enrollee did have visual hallucinations for the past nine years. It does not appear medically 
necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a 
lower level of care as the enrollee did not have dangerousness to self or others, perceptual disturbance 
including delusions, but did have visual hallucinations for the past nine years. The health plans denial of 
inpatient psychiatric services appears appropriate. This enrollee does not appear to require inpatient mental 
health treatment as he was not a danger to himself or others and was cooperative and compliant. It does not 
appear that active treatment was taking place. It does not appear that the services were reasonably expected to 
improve the enrollees condition or were for the purpose of a diagnosis. It does appear that the records were 
supervised and evaluated by a physician. Based upon the review of the records provided, this enrollee does not 
meet criteria for acute inpatient mental health treatment. 
 
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 continued acute inpatient psychiatric hospital care.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for home health services provided from May 4, 2022, to May 25, 
2022. 
 
You asked the Plan to pay for home health services. You say that an NOA was submitted. The Plan denied 
your request. The Plan says the submitted NOA did not have the correct admission date. 
 
The Plan follows Medicare rules. The rules say that an NOA must be submitted with an admission date that 
matches the from date. 
 We reviewed the file and the Medicare rules. We find that the admission date billed on the NOA does not 
match the from date on the NOA. Therefore, we decided that the Plan does not have to pay for home health 
services provided from May 4, 2022, to May 25, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor (CGM). 
 
You asked the Plan to pre-approve the CGM. You say that it is felt this is needed. The Plan denied your 
request. The Plan says the criteria for a CGM have not been met. 
 
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. Based on this information, we decided that Medicare rules for coverage of the CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor (CGM).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
May 20, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. Based on 
this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, 
we decided that the Plan does not have to pay for the continuous glucose monitor (CGM) supplies rendered on 
May 20, 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 the enrollee meets IRF admission criteria, and their 
ongoing rehabilitative needs warrant an IRF level of care to achieve a safe and sustainable discharge. The Plan 
denied your request. The Plan says criteria for admission to the IRF setting have not been met. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.  While the 
medical record supports a need for physical and/or occupational therapy, there is no documented need for 
intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 36000 billed for date of service May 31, 
2022. 
 
You asked the Plan to pay for procedure code 36000. You say that you disagree with the denial. The Plan 
denied your request. The Plan says procedure code 36000 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 We find that procedure code 36000 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 36000 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 36000 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 36000 billed for date of service May 31, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99214 billed for date of service August 24, 
2022. 
 You asked the Plan to pay for procedure code 99214. You say that the medical records support the billing of 
this code. The Plan denied your request. The Plan says payment for code 99214 is bundled into payment for 
code 20610. 
 
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 99214 
is a column II code to column I code 20610. 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 99214 billed for date of service August 24, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on April 7, 2022. 
 
You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied 
your request. The Plan says the services are not supported or 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. 
 
CPT code(s) 87481, 87653, 87798-91, 87801-81, 87641-91 remain not supported because this code is included in CPT code 87150 and 87801. Therefore, the codes cannot be separately reimbursed. 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.  
 
CPT code 87801-91 remains not supported. The documentation submitted did not include a clear description of 
the organism(s) to be tested. This means we cannot verify the validity and accuracy of the billed service. In 
addition, the submitted medical records do not support that a repeat clinical laboratory test was performed; 
therefore, the billed service cannot be verified. 
 
CPT code 87500-91 remains not supported. The documentation submitted do not support that a repeat clinical 
laboratory test was performed; therefore, the billed service cannot be verified. 
 
CPT code 87150-91 remains not supported. This code is included in CPT code 87500; therefore, it cannot be 
separately reimbursed. In addition, the documentation submitted do not support that a repeat clinical laboratory 
test was performed; therefore, the billed service cannot be verified. Therefore, we decided that the Plan does 
not have to pay for the laboratory services provided on April 7, 2022.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from February 6, 2022 to 
March 7, 2022. 
 
You asked the Plan to pay for the home health services as billed. You say that these service were medically 
necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 
The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this 
information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we 
decided that the Plan does not have to pay for the home health services provided from February 6, 2022 to 
March 7, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services rendered on February 19, 2022. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The Plan must follow Medicare rules. The rules say that the PC and TC for diagnostic services are separately 
payable when furnished in different payment localities. 
 
We looked at the file and Medicare rules. The file shows that the PC and TC were not performed in different 
payment localities. Based on this information, we decided that Medicare rules for coverage of these services 
have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services 
rendered on February 19, 2022.
Appeal type: Other
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a pneumatic compression device (E0652, E0667) to be 
provided by an out-of-network (OON) provider. 
 
You asked the Plan to pre-approve the pneumatic compression device. You say that this devices is medically 
necessary. The Plan denied your request. The Plan says there are network providers available for this device. 
 
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 at issue in this appeal. We found no exception that would require the Plan 
to pre-approve these items. Therefore, we decided that the Plan does not have to pre-approve a pneumatic 
compression device (E0652, E0667) to be provided by an out-of-network (OON) provider.
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 you are getting stronger but need the rehab to regain 
maximum function. The Plan denied your request. The Plan says the request is not medically necessary, the 
services you need can be provided safely in other settings, for example, a skilled nursing facility. 
 
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 your medical problems are stable and there are no complex nursing or rehabilitation 
needs. There is no documented need for intensive rehabilitation services and medically necessary care can be provided in a different level of care. 
 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute IRF admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70559 billed for date of service September 
20, 2022. 
 
You asked the Plan to pay for procedure code 70559. You say that you disagree with the denial. The Plan 
denied your request. The Plan says payment for code 70559 is bundled into payment for code 61781.  
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 70559 
is a column II code to column I code 61781. 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 70559 billed for date of service September 20, 
2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the histocompatibility testing (86812) provided August 29, 
2022. 
 
You asked the Plan to pay for the laboratory services. You say that please review the attached documentation 
and allow payment for CPT code 86812. The Plan denied your request. The Plan says does not meet Medicare 
NCD/LCD criteria. Histocompatibility testing is not a Medicare benefit for the diagnoses as listed on the 
claim (M25.519 - Pain in unspecified shoulder) and is done for screening purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay 
for the histocompatibility testing (86812) provided August 29, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on February 23, 2022. 
 
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The 
Plan denied your request. The Plan says you billed with an incorrect place of service on the claim. 
 
The Plan must follow Medicare rules. Medicare rules say that, for 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 the lab 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 lab services provided on February 23, 2022.