Persius/hicric huggingface dataset:
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 you need IRF care. The Plan denied your request. 
The Plan says you have no acute or complex medical needs identified requiring an IRF stay. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. Medical problems are 
stable. There are no complex nursing or rehabilitation needs. While the documentation does support a need for 
physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 
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. 
 
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: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to waive the copayments for physical therapy visits provided from 
October 22, 2021, to October 29, 2021 
 
You asked the Plan to waive the copayments for physical therapy visits. You say that you did not know there 
was a copayment for your physical therapy visits. You also say that it was not noted with your therapists that 
you had a copayment. The Plan denied your request. The Plan says you have been charged the correct cost 
sharing amount. 
 
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 $35 
copayment for each in-network physical therapy visit.  The records show you had physical therapy visits on October 22, 2021, October 25, 2021, October 27, 2021, 
and October 29, 2021. You have been asked to pay a total of $140, which is a $35 copayment for each physical 
therapy visit ($35 copayment x 4 visits = $140). Physical therapy visits fall within the Outpatient Rehabilitation 
Services benefit category. 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 copayments for physical therapy visits 
provided from October 22, 2021, to October 29, 2021
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 74176 billed for date of service November 
13, 2021. 
 You asked the Plan to pay for procedure code 74176. You say that the patient had multiple exams on this date 
of service. The Plan denied your request. The Plan says payment for code 74176 is bundled into payment for 
74174. 
 
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 74176 
is a column II code to column I code 74174. 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 74176 billed for date of service November 13, 
2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the computed tomography (CT) of the head or brain provided 
on November 9, 2021. 
 You asked the Plan to pay for the CT of the head or brain. You say that you would like reconsideration based 
on the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 70459 
and 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 the computed tomography (CT) of the head or brain provided on 
November 9, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on September 7, 
2021. 
 
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says the billed codes cannot be verified. 
 
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 the 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 laboratory services provided to the enrollee on September 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve endovenous ablation and sclerotherapy for the enrollee. 
 
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary. 
 
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 services. Our reviewer says that the 
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer 
found the record indicates that the plan has approved endovenous ablation of saphenous veins for reflux. The 
rule requires saphenous reflux to be absent or to be treated prior to tributary sclerotherapy. The elements of the 
coverage criteria are not satisfied. The requested service is not recommended.  
 
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 services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve endovenous ablation and sclerotherapy for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a right prosthetic microprocessor replacement. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that prosthetic attachments are covered when 
medically necessary. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the records show that the enrollee 
required the use of a rolling walker with his prosthesis prior to recent illness. This is not consistent with K3 
ambulation and therefore the requested right prosthetic microprocessor replacement is not medically necessary, 
as it exceeds the enrollee's medical 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 these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a right prosthetic microprocessor replacement.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the simple wound repair (12011) provided on June 6, 2021. 
 You asked the Plan to pay for the simple wound repair. You say that you would like reconsideration based on 
the records submitted. The Plan denied your request. The Plan says an edit exists between CPT codes 12011 
and 24650. 
 
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 12011 
is a column II code to column I code 24650. 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 simple wound repair (12011) provided on June 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a semi-electric hospital bed. 
 
You asked the Plan to pre-approve a semi-electric hospital bed. You say that the enrollee would benefit from a 
semi-electric hospital bed. The Plan denied your request. The Plan says the criteria for the requested bed are 
not met. 
 
The Plan must follow Medicare rules. The rules say that a semi-electric hospital bed may be considered 
medically necessary when the patient: 
 
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed; or 2. Requires attachments which can only be attached to a hospital bed; AND 
 
3. Requires frequent changes in body position and/or has an immediate need for a change in body position. 
 
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 a semi-electric hospital bed. Our 
reviewer says that the records do not support that a semi-electric hospital bed is medically reasonable and 
necessary. Our physician reviewer found the documentation doesnt support that the member has a condition 
that requires frequent positioning of the bed and mattress to alleviate pain, promote good body alignment, 
prevent contractures or avoid respiratory infections in a way that an ordinary bed is not able to. Additionally, 
there is no indication that she is unable to reposition herself. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a semi-electric hospital bed have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a semi-electric hospital bed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve six office visits to be rendered by the out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve six office 
visits to be rendered by the out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 77002 billed for date of service October 6, 
2021. 
 
You asked the Plan to pay for procedure code 77002. You did not provide an argument with your appeal 
request. The Plan denied your request. The Plan says you have not billed an appropriate primary procedure 
code to have code 77002 paid. 
 The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. In this case, we have confirmed that code 
procedure code 77002 is an add-on code and has not been billed with an appropriate primary procedure code. 
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 77002 billed for date of service October 6, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Tempus Gene Panel testing provided on October 20, 
2021. 
 
You asked the Plan to pay for the Tempus Gene Panel testing. You say that you would like reconsideration 
because this testing was medically necessary. The Plan denied your request. The Plan says a panel constitutes a 
single procedural service, so one CPT code must be submitted for the panel. 
 
The Plan must follow Medicare rules. Medicare rules say that the submission of claims using individual gene 
CPT codes, when either 5-50 or >50 gene panels are ordered, is considered incorrect coding. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the Tempus Gene Panel testing have not been met. Specifically, this claim was not billed in 
accordance to Medicare guidelines. It is not appropriate to bill this testing with individual gene CPT codes. Therefore, we decided that the Plan does not have to pay for the Tempus Gene Panel testing provided on 
October 20, 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 enrollee has a serious life-threatening 
constellation of acute medical problems that have left them at a functional status below their baseline. 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 and does not need physical medicine and 
rehabilitation (PM&R) physician supervision three (3) times per week (at a minimum) for the ongoing 
management of any active or acute exacerbations of chronic medical conditions. With confusion and baseline 
dementia, it is unlikely that the enrollee would make a significant functional recovery in an IRF in 10-14 days 
as predicted. 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. The enrollee's 
rehabilitation needs can be safely met in an alternate and lower intensity setting such as in a skilled nursing 
facility (SNF). IRF admission is not medically necessary based on 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the removal impacted cerumen using irrigation/lavage, 
unilateral (CPT code 69209) provided on August 16, 2021. 
 
You asked the Plan to pay for the service. 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. 
 
CPT code 69209 has a PC/TC indicator of 5 as found on the PFS Relative Value Files on CMS.gov. This 
indicator identifies codes that describe a service incident to physician services for which payment may not be 
made when they are provided to hospital inpatients or patients in a hospital outpatient department. As per 
review, it is found that member was in the hospital for date of service August 16, 2021, and payment for CPT 
69209 was made on September 23, 2021. Therefore, as the billed POS is 23 for on Emergency Room-Hospital-
A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided. we find the 
Medicare rule for payment of CPT code 69209 rendered August 16, 2021, has not been met. If the provider 
determines that a billing error occurred during the initial submission of the denied claim, the plan will accept a 
submission of a corrected claim to consider service for payment. Based on this information, we decided that 
Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not 
have to pay for the removal impacted cerumen using irrigation/lavage, unilateral (CPT code 69209) provided 
on August 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95941 billed for date of service August 4, 
2021. 
 
You asked the Plan to pay for procedure code 95941. You did not provide an argument for coverage. The Plan 
denied your request. The Plan says this code is not payable by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that codes with a status indicator of 'I' in the 
Medicare Physician Fee Schedule Database are not valid for Medicare purposes.  Medicare uses another code 
for the reporting of these services. In this case, code 95941 has a status indicator of 'I' in the Medicare 
Physician Fee Schedule Database. Therefore, we decided that the Plan does not have to pay for procedure code 
95941 billed for date of service August 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99024 billed for date of service August 26, 
2021. 
 
You asked the Plan to pay for procedure code 99024. You did not provide an argument with your appeal 
request. The Plan denied your request. The Plan says no separate payment is made for code 99024. 
 
The Plan must follow Medicare rules. Medicare rules say that for services that have a status indicator of 'B' on 
the Medicare Physician Fee Schedule Database, payment for these services is always bundled into payment for 
other services.  No separate payment is ever made for these codes. Procedure code 99024 has a status indicator 
of 'B' in the Medicare Physician Fee Schedule Database. 
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99024 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99024 billed for date of service August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 23, 
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 this code has a status indicator of "B." 
 
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 99000 is "Handling and/or conveyance of specimen for 
transfer from the office to a laboratory." 
 
We find that CPT code 99000 is not supported in the medical record. Specifically, this code has a status 
indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment 
for other services not specified. 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 laboratory services 
provided to the enrollee on August 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home infusion therapy services to be provided by an 
out-of-network (OON) provider. 
 
You asked the Plan to pre-approve home infusion therapy services. You say that this patient chooses to use this 
provider for his treatment and this provider has been a previous patient in the past. You also say that this 
provider is the only home infusion center in the area, and if the patient had to use the suggested provider, he 
would have to travel an hour out of his way to use the facility and he is unable to do so. The Plan denied your 
request. The Plan says this service is available by a provider in the network who can provide the service and 
have the infusions delivered to the enrollee's home. 
 
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/services at issue in this appeal. We found no exception that would require 
the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve 
home infusion therapy services to be provided by an out-of-network (OON) provider.