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

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on 
October 26, 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 the provider did not bill as required by Medicare coding regulations. 
 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 76705 
is a column II code to column I code 93976. 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 imaging services provided to the enrollee on October 26, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you are not able to physically care for yourself at 
home without someone being with you at all times.  You said that you need help getting from the bed to a 
wheelchair as well as being fed. The Plan denied your request. The Plan says SNF care is not medically 
necessary for you. 
 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 daily 
skilled services are not necessary. Our physician reviewer found your pulmonary and respiratory status has 
remained stable and you can walk 50 feet with modified independence. The records show that you do not 
require skilled nursing or therapy services on a daily basis. 
 
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 not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colpopexy procedure provided on August 20, 2021, billed 
with code 57262. 
 You asked the Plan to pay for the colpopexy procedure as billed. You say that the records support payment for 
this claim. The Plan denied your request. The Plan says the Column 2 code 57282 was not billed with an NCCI 
modifier. 
 
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 57282 
is a column II code to column I code 58262. 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 colpopexy procedure provided on August 20, 2021, billed 
with code 57262.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the colonoscopy rendered on May 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 45380 is not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
 
 
 The provider submitted a claim for procedure codes 45385 (colonoscopy with lesion removal) and 45380 
(colonoscopy and biopsy). Code 45380 is a column II code with a modifier indicator of 1 when billed with 
column I code 45385. Code 45380 was not billed with an appropriate modifier to allow for separate payment. 
Therefore, we decided that the Plan does not have to pay for the colonoscopy rendered on May 11, 2021.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve SNF care. 
 
You asked the Plan to pre-approve SNF care. You say that the member has reached the maximum amount of 
days approved at the rehab hospital. You say that she still needs continued therapy in order to return home and 
would benefit from SNF services. The Plan denied your request. The Plan says transfer to a SNF for inpatient 
skilled rehab services is not medically necessary. 
  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 
skilled nursing services are not necessary. Our physician reviewer found that the enrollee may benefit from 
skilled therapy services, but it is not medically necessary to provide skilled therapy services on a daily basis in 
a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve SNF care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee. 
 
You asked the Plan to pre-approve SNF services. You say that SNF services are medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met. 
 
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 no required skilled nursing services are 
identified in the medical records. The documentation does not support that it is medically reasonable and 
necessary to provide skilled therapy services on a "daily basis" on an inpatient basis, in a skilled nursing 
facility setting. Medicare coverage criteria are not met. 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 for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Blood bank physician services (86077) provided on 
September 27, 2021. 
 You asked the Plan to pay for code 86077. 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 claims submitted where the unit of service 
exceeds the MUE value cannot be paid when the MAI value is 2.  
 
In this case, the MUE for CPT code 86077 is 1. The MAI value for this code is 2. You billed 2 units of this 
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of code 
86077 have not been met. Therefore, we decided that the Plan does not have to pay for the Blood bank 
physician services (86077) provided on September 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a raised toilet seat purchased on September 7, 2021. 
 
You asked the Plan to pay for a raised toilet seat. You say that the nursing home told you to purchase a raised 
toilet seat because they were out of stock. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that raised toilet seats are not covered 
because they are not primarily medical in nature. While a raised toilet seat may be appropriate in this case, 
neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to 
pay for a raised toilet seat purchased on September 7, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the debridement rendered on September 10, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 11721 (debridement of nails, 6 or more) and 11056 (paring 
or cutting of benign hyperkeratotic lesion). Code 11721 is a column II code with a modifier indicator of 1 when 
billed with column I code 11056. Code 11721 was not billed with an appropriate modifier to allow for separate 
payment. Therefore, we decided that the Plan does not have to pay for the debridement rendered on September 
10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the annual wellness visit provided on September 15, 2021. 
 
You asked the Plan to pay for the annual wellness visit. You say that you would like the Plan to reconsider 
their denial of payment. The Plan denied your request. The Plan says Medicare covers an annual wellness visit 
once every calendar year. You already had this service in the 2021 calendar year on February 24, 2021. 
 
The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once 
every 12 months.  
 
Based on review of the file, an AWV was provided less than 12 months prior to the visit at issue in this case. 
Therefore, we decided that the Plan does not have to pay for the annual wellness visit provided on September 
15, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for routine eye exam you received from an out-of-network 
optometrist on March 17, 2021. 
 
You asked the Plan to pay for the routine eye exam. You say that you were told that this provider was in-
network. The Plan denied your request. The Plan says these vision services are not covered because you 
received them from an out-of-network provider, and you did not have prior authorization to go to this out-of-
network provider. 
 
Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine 
vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in 
this case. The Plan covers these services received from a doctor in the Plans vision network. 
 
We looked at the file and the Plan's rules. According to the information provided, the optometrist you saw is 
not part of the Plans vision network. Based on this information, we decided that the Plan's rules for coverage 
of the routine eye exam have not been met. Therefore, we decided that the Plan does not have to pay for routine 
eye exam you received from an out-of-network optometrist on March 17, 2021.  
 Your complaint about being told that this provider was in-network by the sales representative when you joined 
the Plan is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be 
answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
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 she requires an IRF hospitalization with daily 
physician visits, 24-hour rehab nursing care, intensive therapies to optimize mobility and regain the ability to 
perform activities of daily living. You say that services cannot safely be met with home health services or a 
SNF and authorization should be granted. The Plan denied your request. The Plan says care can safely be 
received in other settings. 
 
  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 the enrollee's nursing, medical and rehabilitation needs do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
documentation supports that services may be provided at a lower 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 the laboratory services rendered on September 14, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 83789 is not supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 83789 is mass spectrometry and tandem mass 
spectrometry (eg, MS, MS/MS, MALDI, MS-TOF, QTOF), non-drug analyte(s) not elsewhere specified, 
qualitative or quantitative, each specimen. 
 
We find that CPT code 83789 is not supported in the medical record. Specifically, there is no documentation of 
a complete description of this code being performed. 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 September 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for out of network lab services provided to the enrollee on 
October 22, 2021. 
 
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your 
request. The Plan says the enrollee did not have prior authorization for out of network care. 
 
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the 
Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 
The 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 out of network lab services provided to the 
enrollee on October 22, 2021.
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 these services are medically necessary. The Plan 
denied your request. The Plan says Medicare coverage criteria are not met.  
 
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 the documentation does not support that 
it is medically reasonable and necessary to provide skilled therapy services on a "daily basis" on an inpatient 
basis, in a skilled nursing facility setting. Medicare coverage criteria are not met.  
 
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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided to the enrollee on August 30, 2021, and 
billed under code 83789. You asked the Plan to pay for code 83789. You say that this claim should be paid. The Plan denied your 
request. The Plan says while a portion of this claim was paid, code 83789-59 is not separately reimbursed when 
billed for specimen validity testing on urine specimens utilized for drug testing. In addition, this code 
represents a not elsewhere specified code. However, a complete description of the not elsewhere specified code 
was not included. 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 a Community Mental Health Center POS 53. Therefore, the billed code and 
appended modifier cannot be verified. 
 
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few 
tests listed in the Medicare rules section, are not covered. The rules say that services must be reported for valid 
testing reasons and with the appropriate place of service code. Insufficient medical records were submitted to 
show this testing was done appropriately. In addition, the POS code reported is not valid. Therefore, we 
decided that the Plan does not have to pay for lab services provided to the enrollee on August 30, 2021 and 
billed under code 83789.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the laboratory services provided on September 4, 2021. 
 
You asked the Plan to pay for the laboratory services. 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 for purposes of payment under the Medicare 
Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting 
where the beneficiary receives the face to-face service. 
 
 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. Specifically, this claim was billed with the laboratory 
POS code. The records do not support that the member's face-to-face service was rendered in a laboratory 
setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on 
September 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the surgical assistant services related to a laminectomy 
provided on October 6, 2021, billed with code 63042. 
 You asked the Plan to pay for the surgical services as billed. You say that this should be paid due to medical 
necessity. The Plan denied your request. The Plan says 63047 was paid; however, the required NCCI modifier 
for 63042 was not reported. 
 
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 63042 
is a column II code to column I code 63047. 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 surgical assistant services related to a laminectomy provided 
on October 6, 2021, billed with code 63042.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the mass spectrometry rendered on August 11, 2021. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not separately payable. 
 
The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically 
appropriate NCCI modifier is used to report the reason it should be paid as well. 
 
The provider submitted a claim for procedure codes 83789 (mass spectrometry) and 80307 (presumptive drug 
testing). Code 83789 is a column II code with a modifier indicator of 1 when billed with column I code 80307. 
Code 83789 was not billed with an appropriate modifier to allow for separate payment. The file does not 
support the -59 modifier as a separate and distinct procedural service. Therefore, we decided that the Plan does 
not have to pay for the mass spectrometry rendered on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy 
assistant on August 14, 2021. 
 
You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-
contracted providers at the preferred provider rate when services are not available from preferred providers in 
the service area. You say that the in-network benefits should be honored, and the claim processed for payment. 
The Plan denied your request. The Plan says the code is not appropriate for the service billed. 
 
The Plan must follow Medicare rules. Medicare rules say that the services of a physical therapy assistant (PTA) 
shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they 
do not meet the qualifications of a therapist.  
  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse 
practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's 
professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services 
provided by a physical therapy assistant on August 14, 2021.