Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the foot support (CPT code L3020). 
 
You asked the Plan to pre-approve the foot support. You say that the items are necessary. The Plan denied your 
request. The Plan says the notes do not state your shoes are an integral part of a covered brace and if they are 
medically necessary for the proper functioning on the brace. 
 
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with 
diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.   
 
Records show that you do not suffer from diabetic foot disease, and you do not wear a leg brace. Although 
orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your 
condition. Therefore, we decided that the Plan does not have to pre-approve the foot support (CPT code 
L3020).
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the chest x-ray provided on December 1, 2021. 
 
You asked the Plan to pay for the chest x-ray. You say that the enrollee had multiple exams on this date of 
service. The Plan denied your request. The Plan says an appropriate modifier was not 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. 
 
The file shows that CPT code 71045 was billed with code 74022. We find that CPT code 71045 may be eligible 
for payment when billed with this code pair. The claim does not show that the code at issue was billed with a 
modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the 
chest x-ray have not been met. Therefore, we decided that the Plan does not have to pay for the chest x-ray 
provided on December 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70450) provided on 
October 17, 2021. 
 
You asked the Plan to pay for code 70450. 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 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 the Computed tomography (CT) scan (70450) provided on 
October 17, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Computed tomography (CT) scan (70480) provided on 
December 5, 2021. 
 
You asked the Plan to pay for code 70480. 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 70480 
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 the Computed tomography (CT) scan (70480) provided on 
December 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pharmacogenomics panel testing provided on May 25, 
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 look at the file and the rules. The claim shows that the panel testing 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 have not been met. Therefore, we decided that 
the Plan does not have to pay for the pharmacogenomics panel testing provided on May 25, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the office visit provided on September 8, 2021. 
 
You asked the Plan to pay for the services provided. You say that the nurse evaluated the enrollee before his 
treatment. The Plan denied your request. The Plan says this code is 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 CPT code. 
 
In this case, the CPT Code Manual definition of code 99211 is office or other outpatient visit for the evaluation 
and management of an established patient that may not require the presence of a physician or other qualified 
health care professional.  
 
The file shows that CPT code 99211 was billed with code 96413. We find that CPT code 99211 is not 
reportable with chemotherapy and non-chemotherapy drug/substance administration HCPCS/CPT codes. Based 
on this information, we decided that Medicare rules for coverage of the services provided have not been met. 
Therefore, we decided that the Plan does not have to pay for the office visit provided on September 8, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services (CPT code 87150) provided on 
January 15, 2021. 
 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 service is not covered as billed. 
 
The Plan must follow Medicare rules. 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. CPT code 87150 (11 
units) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of 
the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was 
obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting POS 11. Therefore, we decided that the Plan does not have 
to pay for the laboratory services (CPT code 87150) provided on January 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mouth guards provided on August 17, 2021, and 
September 16, 2021. 
 
You asked the Plan to pay for the device. You say that the mouth guard is needed to prevent the erosion of your 
jaw joints. The Plan denied your request. The Plan says this is not a payable code. 
 
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 S8262 is mandibular orthopedic repositioning device, 
each.  
 We find that at the time of service, CPT code S8262 was not an active code. CPT code S8262 was also not 
valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for the services you 
received. Based on this information, we decided that Medicare rules for coverage of the device have not been 
met. Therefore, we decided that the Plan does not have to pay for the mouth guards provided on August 17, 
2021, and September 16, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided from October 1, 2021, 
through October 6, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says that 
the inpatient admission was not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
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 acute inpatient hospital care. Our reviewer 
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician 
reviewer found that the record showed that at the time of inpatient admission the admitting physician 
reasonably expected that the enrollees necessary hospital care (including earlier emergency department and/or 
observation care) would span two midnights. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan 
has to pay for the acute inpatient hospital care provided from October 1, 2021, through October 6, 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: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services for the enrollee. 
 
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 member does not require an interdisciplinary team approach to 
delivery of rehabilitation 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 enrollee is medically stable and does not need physical medicine and rehabilitation physician close supervision 
3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic 
medical conditions. No acute rehab nursing needs identified or documented in the record. The enrollee does not 
need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with 
multidisciplinary approach to daily therapy in an IRF. She will not make a significant functional recovery in a 
predicted seven to ten days in an IRF starting at such current dependent level. At the current level of function, 
the enrollee's rehab can be safely provided at a lower intensity and alternate setting such as in an SNF. Our 
physician reviewer found that the enrollee's 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 for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the hearing aids provided on May 27, 2021. 
 
You asked the Plan to reimburse you for the hearing aids. You say that you were advised the provider was in 
network with your plan. You say that come to find out they are not in network with the hearing benefit. You 
say that you were unaware that you had to use the Plan's hearing benefit program. You also say that you should 
be reimbursed the $500 hearing benefit. The Plan denied your request. The Plan says the provider in this case is 
out of network. The Plan says that hearing aids ordered through providers other than the Plan's Hearing vendor 
are not covered. 
 
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. The Plan pays for 
hearing aids only when ordered through providers other than the Plan's Hearing vendor.  
 
We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for 
coverage of the hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse 
you for the hearing aids provided on May 27, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Durolane (CPT code J7318). 
 
You asked the Plan to pre-approve the medication. You say that the medication is necessary. The Plan denied 
your request. The Plan says they do not have a record from the enrollee's prescriber that shows they have tried 
one of the preferred drugs (Orthovisc, Synvisc or Synvisc One), or that they have medical reasons that prevent 
the enrollee from using one of them. 
 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to 
implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain 
Part B medications. 
 
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 medication. Our physician reviewer 
found the review has determined that the requested Durolane injections are not medically necessary or 
reasonable. 
 
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 medication have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Durolane (CPT code J7318).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lab tests provided on February 16, 2021. 
 
You asked the Plan to pay for the lab tests. You say that the claim should be paid according to state laws. The 
Plan denied your request. The Plan says the procedure code is inconsistent with the place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and the rules. Diagnostic tests performed by the ambulatory surgical center are not 
covered under Part B and are not to be billed as diagnostic tests. Based on this information, we decided that 
Medicare rules for coverage of the lab tests have not been met. Therefore, we decided that the Plan does not 
have to pay for the lab tests provided on February 16, 2021.
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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. 
 
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 enrollee is medically stable does not need physical medicine and rehabilitation 
(PM&R) physician close supervision three (3) times per week (at a minimum) for the ongoing management of 
any active or acute exacerbations of chronic medical conditions. No acute rehabilitation nursing needs 
identified or documented in the record. While the enrollee may benefit from physical therapy (PT), and occupational therapy (OT), the enrollee does not need intensive therapies, consisting of at least 3 hours of 
therapy per day at least five (5) days per week with multidisciplinary approach to daily therapy in an IRF. At 
the current level of function, he needs routine PT, and OT in a skilled nursing facility (SNF). The enrollee's 
rehabilitation can be safely provided at a lower intensity and alternate setting such as in an SNF. IRF admission 
is not medically necessary based on medical stability and lack of medical complexity and lack of acute 
rehabilitation nursing needs. The enrollee's rehabilitation needs can be met at a lower intensity setting such as 
in an SNF. Document does not support the necessity for admission to an IRF. 
 
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: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services. 
 
You asked the Plan to pre-approve SNF services. You say that the enrollee needs rehabilitation daily and at the 
hospital she is just lying around. You say that the enrollee is not reaching her baseline for daily living. The Plan 
denied your request. The Plan says the records do not show that the enrollee requires daily skilled nursing or 
skilled therapy in a SNF 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 services. Our reviewer says that 
daily skilled services are not necessary. Our physician reviewer found there is no documentation that the 
enrollee requires skilled nursing services. Records do not document the need for intravenous medications, new 
tube feeding, or ostomy care or daily complex wound care. The documentation does support the need for 
skilled therapy services, but not on a daily basis. Provided records do not document a significant decline in the 
enrollee's functional status compared to her recent baseline to necessitate daily inpatient skilled therapy 
services. There is no documentation that the enrollee requires the services on an inpatient basis, only in a 
skilled nursing facility setting. Services in the home with home health care or in a long-term care facility on a 
part time basis appear appropriate in this case. 
 
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 skilled nursing facility (SNF) services.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76942-59 billed for date of service 
September 20, 2021. 
 
You asked the Plan to pay for procedure code 76942-59. You say that you have provided medical records to 
support payment of this code. The Plan denied your request. The Plan says separate payment for code 76942-59 
is not allowed because use of the -59 modifier is not supported in the medical record. You also billed code 
76872, and 76942 is not typically separately payable from this code. 
 
The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the 
service billed with the modifier indicates a distinct procedural service.   
 
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 procedure code 76942-59 Our reviewer says 
that the use of the -59 modifier with code 76942 is not supported in the medical record. Our physician reviewer 
found you reported code 76942, which is ultrasonic guidance for needle placement (eg, biopsy, aspiration, 
injection, localization device), imaging supervision and interpretation in addition to ultrasound, transrectal procedure (code 76872). The operative report does not support modifier -59 in this case.  These procedures 
were performed during the same session and would not be reported separately.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of procedure code 76942-59 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 76942-59 billed for date of service September 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting 
from May 18, 2021, to May 22, 2021. 
 
You asked the Plan to pay for the self-administered drugs. You say that you received a bill from the hospital for 
services you received in the amount of $464.10. The Plan denied your request.  The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs 
are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not 
covered under Medicare Part B. 
 
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-
administered drugs. The self-administered drugs requested here are not among the types which are covered by 
Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs 
provided in an outpatient setting from May 18, 2021, to May 22, 2021.  
 
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that 
administers Part D benefits for further information concerning any benefits and appeal rights.