Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 76140 billed for date of service July 12, 
2022. 
 
You asked the Plan to pay for procedure code 76140. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 76140 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 76140 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of procedure code 76140 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code 76140 billed for date of service July 12, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 71045 billed for date of service March 14, 
2022. 
 
You asked the Plan to pay for procedure code 71045. The Plan denied your request. The Plan says payment for 
code 71045 is bundled into payment for code 36573. 
 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 71045 
is a column II code to column I code 36573. 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 71045 billed for date of service March 14, 2022.
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 the stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary. 
 
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 there is no indication that the enrollee would require skilled rehabilitation in an IRF, 
participating in rehab services 15 hours a week, under the supervision of a physician with at least 3 visits 
weekly to regain or maintain the enrollee's functional status. The enrollee can receive further services 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the appendectomy (44955) provided on June 28, 2022. 
 
You asked the Plan to pay for the appendectomy. 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 appendectomy have not been met. CPT code 44955 was billed 
without an appropriate primary code and not performed by the same practitioner on the same date of service; 
we find that Medicare rule for payment for CPT codes 44955 has not been met. Therefore, we decided that the 
Plan does not have to pay for the appendectomy (44955) provided on June 28, 2022.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pay for the services provided from May 5, 2022, through May 21, 2022. 
 
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your 
request. The Plan says that the HIPPS code listed on the claim was entered but the (denial) edit still generates. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. The Plan failed to give a valid rationale as to why this is being denied. 
Therefore, we decided that the Plan has to pay for the services provided from May 5, 2022, through May 21, 
2022.  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 99140 billed for date of service May 14, 
2022. 
 
You asked the Plan to pay for procedure code 99140. You say that the claim should be paid. The Plan denied 
your request. The Plan says procedure code 99140 is considered bundled and not separately payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99140 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99140 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99140 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99140 billed for date of service May 14, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 83550 billed for date of service February 7, 
2022. 
 
You asked the Plan to pay for procedure code 83550. The Plan denied your request. The Plan says payment for 
code 83550 is bundled into payment for code 84466.  
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 83550 
is a column II code to column I code 84466. 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 83550 billed for date of service February 7, 
2022.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the abdominal aorta ultrasound (CPT code 76706-26) 
provided on June 27, 2022. 
 
You asked the Plan to pay for the service. You say that the procedure was done at the request of the referring 
doctor as the condition proved medical necessity for the service. 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 service have not been met. Review of the file show that this 
was billed with diagnosis code Z13.6 (Encounter for screening for cardiovascular disorders) which is not 
considered as appropriate diagnosis code for an ultrasound screening exam of abdominal aorta as per the above guidelines. Additionally, based on documentation received, it does not include that the patient received the 
screening study for one of the risk categories as listed in above guidelines. Therefore, we decided that the Plan 
does not have to pay for the abdominal aorta ultrasound (CPT code 76706-26) provided on June 27, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the physical therapy services (CPT code 97110) provided on 
August 12, 2022, by an out-of-network provider. 
 
You asked the Plan to pay for the out-of-network services. You say that the claim should be paid. The Plan 
denied your request. The Plan says this provider is out-of-network, the services were not referred by a network 
provider, and the services were not urgent or emergent, nor were they approved in advance. 
 
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 the physical therapy services (CPT code 97110) 
provided on August 12, 2022, by an out-of-network provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the genetic testing provided on March 16, 2022, billed with 
codes 81201, 81292, 81295, 81298, 81317, 81334 and 81351. 
 
You asked the Plan to pay for the genetic testing billed. You say that this testing was medically necessary. The 
Plan denied your request. The Plan says panel testing should be billed using one CPT code on the claim. 
 
The Plan must follow Medicare rules. The rules say that if one laboratory procedure evaluates multiple genes 
using a next generation sequencing (NGS) procedure, the laboratory shall report only one unit of service of one 
genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or 
proprietary laboratory analysis code. 
 
We looked at the file and Medicare rules. This was an NGS panel that was not billed with a single panel code 
as required. Based on this information, we decided that Medicare rules for coverage of the genetic testing billed have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on 
March 16, 2022, billed with codes 81201, 81292, 81295, 81298, 81317, 81334 and 81351.
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 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 there is not a reasonable expectation that this enrollee 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: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the unilateral breast ultrasound (CPT code 76642) provided 
on August 11, 2022. 
 
You asked the Plan to pay for the unilateral breast ultrasound. You say that the claim should be paid. The Plan 
denied your request. The Plan says the services are 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 unilateral breast ultrasound have not been met. CPT code 
76642 is not billed in accordance with Medicare National Correct Coding Initiative Policy. Medically Unlikely 
Edits (MUE). This is not a medical necessity denial. CPT code 76642 has an MUE value of 1 but billed 2 units. 
Therefore, the Medicare rule for payment of this date of service August 11, 2022, claim has not been met. 
Therefore, we decided that the Plan does not have to pay for the unilateral breast ultrasound (CPT code 76642) 
provided on August 11, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S2900 billed for date of service August 17, 
2022. 
 
You asked the Plan to pay for procedure code S2900. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S2900 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S2900 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S2900 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S2900 billed for date of service August 17, 2022.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the diagnostic digital breast tomosynthesis services billed 
with procedure code 77061 for date of service June 15, 2022. 
 
You asked the Plan to pay for the diagnostic digital breast tomosynthesis services billed with procedure code 
77061. You say that you disagree with the Plan's denial. The Plan denied your request. The Plan says the code 
billed for the received services is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
 
 
 We find that procedure code 77061 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code 77061 is not valid for Medicare purposes. Based on this information, we decided that Medicare 
rules for coverage of the diagnostic digital breast tomosynthesis services billed with procedure code 77061 
have not been met. Therefore, we decided that the Plan does not have to pay for the diagnostic digital breast 
tomosynthesis services billed with procedure code 77061 for date of service June 15, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for self-administered drugs provided during the outpatient 
hospital visit from September 4, 2022, to September 7, 2022. 
 
You asked the Plan to pay for self-administered drugs. The Plan denied your request. The Plan says self-
administered drugs given to the member while they are in outpatient basis at a facility and are apt to be covered 
under the members Part D coverage. 
 
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 self-administered drugs provided 
during the outpatient hospital visit from September 4, 2022, to September 7, 2022.  Benefits for 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.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for revision of total knee arthroplasty, with or without allograft; 
femoral and entire tibial component (CPT code 27487) provided from May 11, 2022, through May 13, 2022. 
 
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. We looked at the file and Medicare rules. Based on this information, we 
decided that Medicare rules for coverage of the service have not been met. A status indicator C inpatient 
procedure code 27487 was billed on the outpatient claim. The inpatient procedure does not meet the exception 
1 as found in Medicare Claims Processing Manual, Chapter 4 - Part B Hospital (Including Inpatient Hospital 
Part B and OPPS), Section 180.7 Inpatient-only Services. Procedure code 27487 is listed as an inpatient 
procedure but is not found on the inpatient separate procedure list and per the exception 1 description, the 
inpatient-only service is defined in CPT to be a separate procedure was not met. Per this line item denial of 
27487, all other lines for DOS May 11, 202 were denied OCE Edit 49 - Services on same day as inpatient 
procedure. Therefore, we decided that the Plan does not have to pay for revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component (CPT code 27487) provided from May 11, 2022, 
through May 13, 2022.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code S9500 billed for date of service April 7, 2022 
to April 13, 2022. 
 
You asked the Plan to pay for procedure code S9500. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the billed code is invalid for Medicare purposes. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code S9500 has a Status Indicator of I on the Physician Fee Schedule. This means that 
procedure code S9500 is not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of procedure code S9500 have not been met. Therefore, we decided that the Plan does not 
have to pay for procedure code S9500 billed for date of service April 7, 2022 to April 13, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS device (Current Procedural 
Terminology (CPT) code 33289). 
 
You asked the Plan to pre-approve the CardioMEMS device. You say that the device is necessary. The Plan 
denied your request. The Plan says there remains a dearth of randomized, blinded clinical studies examining 
the long-term clinical outcomes to establish the value of CardioMEMS in patient management. 
 
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 CardioMEMS device. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found there remains a dearth of randomized, blinded clinical studies examining long-term 
clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time the 
CardioMEMS system would not be considered medically appropriate and necessary in this enrollees clinical 
management. 
 
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 CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-approve the CardioMEMS device (Current Procedural Terminology (CPT) code 
33289).
Appeal type: Hospice
Decision: Unfavorable

 
We decided that the Plan does not have to pay for radiology services provided on May 21, 2022. 
 
You asked the Plan to pay for radiology services. The Plan denied your request. The Plan says the member was 
enrolled in hospice on this date of service. Therefore, the claim is the responsibility of traditional Medicare. 
 
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice 
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct 
the provider to bill Medicare directly for these services.  
 
The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, 
we decided that the Plan does not have to pay for radiology services provided on May 21, 2022.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on June 28, 
2022. 
 
You asked the Plan to pay for the psychiatric diagnostic evaluation. You say that you disagree with the Plan's 
denial. The Plan denied your request. The Plan says the services are not payable 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. 
 
We find that CPT code 90791 is not supported in the medical record. Specifically, this service was billed with a 
principal diagnosis of F01.51 (vascular dementia, unspecified severity, with behavioral disturbance). This is an 
incorrect principal diagnosis to be billed for the services rendered. Based on this information, we decided that 
Medicare rules for coverage of the psychiatric diagnostic evaluation have not been met. Therefore, we decided 
that the Plan does not have to pay for the psychiatric diagnostic evaluation provided on June 28, 2022.