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

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service November 
18, 2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for this code is bundled into payment for 
70496 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service November 18, 
2021.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the enrollee is unable to walk and cannot bathe, 
cook, or clean for himself. He required skilled care for rehabilitation. The Plan denied your request. The Plan 
says that the enrollee's needs can be met in a different setting. 
 
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 
records support that SNF admission is medically reasonable and necessary for this enrollee. Our physician 
reviewer found the enrollee is a male who was admitted to the hospital after a fall on 2/22/2022. He has been 
receiving physical, occupational, and speech therapy in the inpatient hospital setting. SNF admission was 
denied on 3/18/2022.  
 
While the enrollee does not have skilled nursing needs, he does have documented skilled therapy needs. The 
enrollee is functioning below the reported baseline. Records do not yet establish that the enrollee has reached a 
new, lower level of function. Daily skilled services are required to establish a maintenance program or to 
prevent deterioration of the enrollees condition. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.   
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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan 
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be 
provided at a lower level of care. 
 
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. The 
complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture 
after a fall. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do 
not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there 
is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation 
that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program 
provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 
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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided from October 
4, 2021, to November 2, 2021. 
 You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. 
The Plan denied your request. The Plan says the enrollee did not receive daily skilled services. 
 
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 pay for the SNF care. Our reviewer says that the 
enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not 
have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled 
professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, 
knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing 
and/or skilled therapy on an inpatient basis in a SNF setting. 
 
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 SNF care have not been met. Therefore, we decided that the Plan does not 
have to pay for the skilled nursing facility (SNF) care provided from October 4, 2021, to November 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Debridement services (11046) provided on August 3, 
2021, and August 10, 2021. 
 
You asked the Plan to pay for code 11046. You say that the medical records support the billing of code 11046-
59 provided on August 3, 2021, and August 10, 2021. The Plan denied your request. The Plan says the medical 
records do not support the billing of code 11046-59 provided on August 3, 2021, and August 10, 2021. 
 
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 11046 is  Debridement, muscle and/or fascia (includes 
epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (List 
separately in addition to code for primary procedure). 
 
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 code 11046. Our reviewer says that the medical records do not support the billing of code 11046-59 provided on August 3, 2021, and August 10, 2021. Our reviewer 
found the review has determined that Current Procedural Terminology (CPT) code 11046-59 was not 
supported. The documentation submitted did not include documentation of Debridement, muscle and/or fascia 
(includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof 
(List separately in addition to code for primary procedure); therefore, the billed service cannot be verified. The 
review has determined that the medical records did not support the billing of code 11046-59 provided on 
August 3, 2021, and August 10, 2021. 
 
We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 11046 have not been met. Therefore, we decided that the Plan does not 
have to pay for the Debridement services (11046) provided on August 3, 2021, and August 10, 2021.
Appeal type: Lab
Decision: Partially Favorable

 
We decided that the Plan has to pay for the drug testing service billed with code G0483. We decided that the 
Plan does not have to pay for the drug testing service billed with code G0480 and the specimen handling 
service billed with code 99000.  
 
You asked the Plan to pay for codes G0483, G0480, and 99000. You say that you would like the Plan to 
reconsider their denial of payment. The Plan says that an edit exists between codes G0483 and G0480 and code 
99000 has a status code of B. 
 
We decided that the Plan has to pay for the drug testing service billed with code G0483.  
 
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent 
efforts to gather and forward information to the Independent Review Entity (IRE).  
 
We looked at the file and Medicare rules. Based on this information we have determined that Medicare criteria 
for coverage have been met. Specifically, the Plan has not forwarded any evidence as to why CPT code G0483 
is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. In this 
case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the 
Plan has to pay for the drug testing service billed with CPT code G0483. 
 
We also decided that the Plan does not have to pay for the drug testing service billed with code G0480 
and the specimen handling service billed with code 99000. 
 
  The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. We looked 
at the file and Medicare rules. Based on this information we have determined that Medicare criteria for 
coverage have not been met. Specifically, we have confirmed that CPT code G0480 is a column II code to 
column I code G0483 which was billed on the same claim. This code pair does not allow a modifier to bypass 
the edit. G0480 is not eligible for separate reimbursement in this case. Additionally, CPT code 99000 has a 
status code of B. This means that the payment for CPT code 99000 is bundled into the payment for another 
procedure or service. Therefore, we decided that the Plan does not have to pay for the drug testing service 
billed with CPT code G0480 and the specimen handling service billed with CPT code 99000. 
 
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: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 70450 billed for date of service December 4, 
2021. 
 You asked the Plan to pay for procedure code 70450. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for this code is bundled into payment for 
70496. 
 
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 70450 
is a column II code to column I code 70496. 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 70450 billed for date of service December 4, 
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77600-59-XU billed for date of service 
October 11, 2021. 
 
You asked the Plan to pay for procedure code 77600-59-XU. You did not provide an argument for coverage 
with your appeal request. The Plan denied your request. The Plan says you billed with an incorrect combination 
of modifiers. 
 
The Plan must follow Medicare rules. The rules state that providers should bill either a -59 modifier or a -XU 
modifier, but not both together.  In this case, you have billed both a -59 and a -XU modifier on the same 
procedure code. 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 procedure code 77600-59-XU billed 
for date of service October 11, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (81291) provided July 13, 2021. 
 
You asked the Plan to pay for the lab services. You say that this test was medically necessary. The Plan denied 
your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that MTHFR gene testing is non-covered except for 
pregnant patients. 
 
We looked at the file and Medicare rules. The record does not show the enrollee was pregnant, therefore this 
test is non-covered. Based on this information, we decided that Medicare rules for coverage of the lab services 
have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81291) provided 
July 13, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services (81291) provided on July 30, 2021, by an 
out-of-network (OON) provider. 
 
You asked the Plan to pay for laboratory services. You say that based on the information submitted in this 
appeal and the Medicare local coverage determination, you would like this appeal reconsidered and for the Plan 
to cover this service as medically necessary. The Plan denied your request. The Plan says the rendering 
provider is a non-participating provider and the referring provider involved in these services is a non-
participating provider with the Plan. The Plan also says that they did not authorize any services for the 
rendering provider or the referring 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 (81291) provided on July 30, 
2021, by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayment and coinsurance for a cardiovascular stress test 
and regadenoson injection provided on October 29, 2021. 
 
You asked the Plan to waive the copayment and coinsurance for the stress test and injection. You say that the 
procedure should be covered in full. The Plan denied your request. The Plan says the correct copayment and 
coinsurance was applied. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as 
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $25 copayment for diagnostic procedures and tests provided at a specialist's office. 
 
Your contract with the Plan also clearly says that you must pay a 20% coinsurance for Part B drugs. 
 
You have been asked to pay a $25 copayment for the stress test. The stress test falls within the Outpatient 
Diagnostic Tests and Therapeutic Services and Supplies benefit category. You have also been asked to pay 
$47.76 for the injection, which is 20% of the allowed amount ($238.80 allowed amount x 20% coinsurance = 
$47.76). The injection falls within the Medicare Part B Prescription Drugs benefit category. The total for the 
visit is $72.76. This means that you have been asked to pay the correct amount based on your contract with the 
Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, 
we decided that the Plan does not have to waive the copayment and coinsurance for a cardiovascular stress test 
and regadenoson injection provided on October 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay an additional amount for eyeglasses provided on 
November 3, 2021. 
 You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says 
the claim processed correctly. 
 
The Plan contract says covered eyeglasses after cataract surgery includes standard frames and lenses as defined 
by Medicare. Any upgrades are not covered (including, but not limited to, deluxe frames, tinting, progressive 
lenses, or anti-reflective coating). 
 
We looked at the file, the Medicare rules and the Plan's rules. The file shows that the Plan processed the claim 
correctly. Covered eyeglasses after cataract surgery includes standard frames and lenses as defined by 
Medicare; any upgrades are not covered (including, but not limited to, deluxe frames, tinting, progressive 
lenses, or anti-reflective coating). Therefore, we decided that the Plan does not have to pay an additional 
amount for eyeglasses provided on November 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the Tricuspid Clip and inpatient hospital admission for 
the enrollee. 
 
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The 
Plan denied your request. The Plan says that the clinical value and effectiveness of MitraClip in the setting of 
tricuspid regurgitation has not been demonstrated in the peer-reviewed literature. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 these services. Our reviewer says that 
the requested services are not considered medically reasonable and necessary in this case. Based on current 
clinical guidelines, there are insufficient randomized clinical data at this time to support the use of transcatheter 
tricuspid valve repair (TTVR) in this setting. Our physician reviewer found that the enrollee's condition does 
not meet criteria for coverage of these services. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve the Tricuspid Clip and inpatient hospital admission for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a MyoPro powered upper extremity orthosis. 
 
You asked the Plan to pre-approve the MyoPro orthosis. You say that this device is needed to allow the 
enrollee more use of her arm. The Plan denied your request. The Plan says this is not a medically necessary 
device. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are 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 the MyoPro orthosis. Our reviewer says 
that the requested items are not considered medically reasonable and necessary in this case. Our physician 
reviewer found the enrollee has a history of spastic hemiplegia due to a stroke in 2011. The MyoPro is not 
known to be effective, based on scientific evidence, professional standards and expert opinion, in improving 
health outcomes in stroke patients. The MyoPro is not in widespread use based on scientific evidence. There is 
insufficient evidence in the literature that the MyoPro Orthosis will improve the long-term outcomes for this 
patient, improve hemiparetic arm function, or be safe for long term use. There is insufficient evidence in the 
literature that this device will increase participation in bimanual activities. 
 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 MyoPro orthosis have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a MyoPro powered upper extremity orthosis.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99072 billed for date of service September 3, 
2021. 
 
You asked the Plan to pay for procedure code 99022. You say that the Plan has paid you an unconscionably 
low rate for the services provided. The Plan denied your request. The Plan says no separate payment is made 
for this code. 
 
The Plan must follow Medicare rules. Medicare rules say that payment for codes with a status indicator of 'B' 
on the Medicare Physician Fee Schedule Database is always bundled into payment for other services.  No 
separate payment is ever made for these codes. Procedure code 99072 has a status indicator of B on the 
Medicare Physician Fee Schedule Database. Therefore, we decided that the Plan does not have to pay for 
procedure code 99072 billed for date of service September 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77600-59-XU billed for date of service 
October 12, 2021. 
 
You asked the Plan to pay for procedure code 77600-59-XU. You did not provide an argument for coverage 
with your appeal request. The Plan denied your request. The Plan says you billed with an incorrect combination 
of modifiers. 
 
The Plan must follow Medicare rules. The rules state that providers should bill either a -59 modifier or a -XU 
modifier, but not both together.  In this case, you have billed both a -59 and a -XU modifier on the same 
procedure code. 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 procedure code 77600-59-XU billed 
for date of service October 12, 2021.