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

 
We decided that the Plan does not have to pay for the genetic testing provided on June 30, 2021. 
 
You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed 
with the incorrect place of service. 
 
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or 
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.  
 
We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records do not show that the specimen was collected in a laboratory. This 
means that the claim was billed with the incorrect POS code. Based on this information, we decided that 
Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have 
to pay for the genetic testing provided on June 30, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pay for the contrast injection (36598) provided on March 10, 2021. 
 
You asked the Plan to pay for the contrast injection. You say that you would like reconsideration because this 
service was billed correctly and is payable. The Plan denied your request. The Plan says that CPT code 36598 
has a status indicator of T so payment is bundled into another CPT 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.  
 
We find that CPT code 36598 is supported in the record. Specifically, CPT code 36598 has a status indicator of 
T. This means that this service is payable when there are no other payable services on the claim. In this case, 
there are no other payable services on this claim. CPT code 36593 is a technical component only code and 
therefore not payable to the physician. Separate reimbursement is appropriate for CPT code 36598. Based on 
this information, we decided that Medicare rules for coverage of the contrast injection have been met. 
Therefore, we decided that the Plan has to pay for the contrast injection (36598) provided on March 10, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services (82306, 82310, 82728, 83540, 83550, 83970, 
84100) provided August 2, 2021. 
 
You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan 
denied your request. The Plan says these services are not eligible for separate payment. 
 
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 codes 82306, 82310, 82728, 83540, 83550, 83970, & 84100 are not supported in the medical 
record. Specifically, payment for end-stage renal disease related lab services is included in payment for the 
dialysis services. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (82306, 82310, 
82728, 83540, 83550, 83970, 84100) provided August 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the inpatient services provided from September 16, 2020, to 
September 22, 2020. 
 You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed DRG is not 
supported. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the 
reported principal and secondary diagnosis codes.   
 
In this case, you billed the inpatient services provided with diagnosis code N17.9. We asked our physician 
reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was 
correct in denying the request to pay for the services. Our reviewer says that the use of diagnosis code N17.9 is 
not supported by the records provided. Our physician reviewer found that during this stay, a chest x-ray showed 
scarring and discoid atelectasis seen on the right mid lung and opacity in the left lower lobe, possibly 
representing infiltrate superimposed on chronic scarring. A CT scan of the chest without contrast noted 
emphysema and some scar versus atelectasis in the right lower lobe and left lower lobe as well as right upper 
lobe minor fissure, very small left pleural effusion, mild enlarged heart size. The enrollee was started on 
empiric IV antibiotics for community-acquired pneumonia as well as steroids. He continued to improve 
considerably throughout hospital course and was weaned down to baseline oxygen requirement. Diarrhea 
resolved, and he was discharged to subacute rehabilitation with 2 more days of Doxycycline and Prednisone to 
complete a seven-day course. The review has determined that the use of diagnosis code N17.9 is not supported 
by the records provided. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the 
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay 
for the inpatient services provided from September 16, 2020, to September 22, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pay for outpatient therapy services (97110) provided July 20, 2021. 
 
You asked the Plan to pay for the outpatient therapy services. You say that these services were medically 
necessary. The Plan denied your request. The Plan says the documentation does not support the billed services. 
 
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 97110 is not supported in the medical record. Specifically, the record shows this service 
was provided in the home setting by a therapy assistant. There is a more appropriate code that describes this 
service (G0157). Based on this information, we decided that Medicare rules for coverage of the outpatient 
therapy services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient 
therapy services (97110) provided July 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 stay is medically necessary. The Plan denied 
your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the 
enrollee's medical and therapy needs could be met in a skilled nursing unit. 
 
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 complexity of the members nursing, medical and rehabilitation needs do not 
require an acute rehabilitation hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
The member does not require treatment by multiple therapies, including either physical therapy or occupational therapy, at an intensive rehabilitation therapy program. The member continues to have a need for skilled 
therapy with ongoing safety concerns and a potential for functional improvement; however, the documentation 
does not support that they would meet criteria for admission to an acute inpatient rehabilitation facility. There 
is no indication that the member would require skilled rehabilitation in an IRF, participating in rehabilitation 
services fifteen (15) hours a week, under the supervision of a physician with at least three (3) visits weekly to 
regain or maintain their functional status. The member 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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a core buildup, including any pins when required 
(D2950) and a retainer crown, porcelain fused to high noble metal (D6750) for tooth # 2. 
 
You asked the Plan to pre-approve a core buildup and a retainer crown. You say that you are in extreme pain 
and you need these services to be authorized and as soon as possible. The Plan denied your request. The Plan 
says x-rays of your teeth do not show that this dental work is medically necessary or that it will improve your 
dental health. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. The Plan covers a core buildup 
and a retainer crown when the services are medically necessary and reasonable.  
 
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 core buildup and a retainer crown. 
Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation 
submitted does not meet the criteria for coverage for a core buildup and retainer crown for tooth #2 due to the 
poor periodontal prognosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
the Plan's rules for coverage of a core buildup and a retainer crown have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a core buildup, including any pins when required (D2950) and a 
retainer crown, porcelain fused to high noble metal (D6750) for tooth # 2.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve continued SNF care. You say that the requested continued SNF care is 
medically necessary. The Plan denied your request. The Plan says the requested continued SNF care does not 
meet criteria. 
 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 continued SNF care. Our reviewer says 
that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral 
medications, insulin, had stable vital signs and his lungs were clear. The enrollee was at a moderate to maximal 
assist level with bed mobility and transfers. The enrollee does not require skilled nursing or therapy services on 
a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient 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 continued SNF care have not been met. Therefore, we decided that the Plan 
does not have to pre-approve continued skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the 
enrollee from September 13, 2021, to October 12, 2021. 
 You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your 
request. The Plan says based on the records submitted, the enrollee did not receive a skilled level of care. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors 
listed in the Medicare rules section are met. Custodial care is not covered. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that daily 
skilled services are not necessary. Our physician reviewer found at the time of admission, the enrollee required 
skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing 
needs. As of 9/13/21 the enrollee did not require any skilled nursing or rehab services on a daily basis. She was 
not expected to make measurable gains within a reasonable and predictable period of time or require skilled 
therapy to prevent deterioration with mobility or ADLs. The enrollee did not require skilled therapy to establish 
a safe and effective maintenance program. As a practical matter, the enrollee did not require any skilled 
services on an inpatient basis, at a SNF level of care as of 9/13/21. 
 
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 pay for skilled nursing facility (SNF) services provided to the enrollee from September 13, 2021, to 
October 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for ambulance services provided to the enrollee on October 1, 
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 an invalid modifier was used in this case. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
 
 
 
 
 
 
 The ambulance company did not provide transport services on October 1, 2021. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for ambulance services provided to the enrollee on 
October 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the cervical cancer screening rendered on September 29, 
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 covered as billed. 
 
The Plan must follow Medicare rules. The rules say that, effective for dates of service on and after July 1, 
2011, A/B MACs shall automatically deny claim line(s) items submitted with a GZ modifier. 
 
We looked at the file and Medicare rules. The file shows that procedure code G0101 (cervical and vaginal 
cancer screening) was billed with the -GZ modifier. Therefore, we decided that the Plan does not have to pay 
for the cervical cancer screening rendered on September 29, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the interpretation of the computed tomography (CT) scan of 
the head provided on November 1, 2021, billed with code 70450. 
 You asked the Plan to pay for the CT scan interpretation as billed. You say that this should be paid as the 
services were rendered. The Plan denied your request. The Plan says this was not billed with a required 
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 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 interpretation of the computed tomography (CT) scan of the 
head provided on November 1, 2021, billed with code 70450.
Appeal type: Testing
Decision: Favorable

 
We decided that the Plan has to reduce the copayment for an echocardiography billed by the hospital and 
rendered by a specialist on September 14, 2021. 
 
You asked the Plan to reduce the copayment for the echocardiography. You say that the services should be 
covered and the copayment applied is incorrect. The Plan denied your request. The Plan says that the cost-
sharing applied correctly based on the services provided. 
 
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your 
contract with the Plan says that enrollees must pay a $10 copayment for diagnostic tests billed by the hospital 
from a specialty physician.  
 
The Plan says you must pay a $100 copayment for an echocardiography. Based on the Plan contract, however, 
you cannot be asked to pay more than a $10 copayment for an echocardiography. The ultrasound billed is not 
considered a surgical procedure. The Plan contract clearly says diagnostic tests from a specialty physician 
billed by the hospital apply a $10 copayment. Therefore, we decided that the Plan has to reduce the copayment 
for an echocardiography billed by the hospital and rendered by a specialist on September 14, 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: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for genetic testing (81479) provided June 25, 2021. 
 
You asked the Plan to pay for the genetic testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says coverage criteria has not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that SelectMDx is clinically useful in males with 
previous negative prostate biopsy who are being considered for repeat biopsy. 
 
We looked at the file and Medicare rules. The record does not show a previous negative prostate biopsy. Based 
on this information, we decided that Medicare rules for coverage of the genetic testing have not been met. 
Therefore, we decided that the Plan does not have to pay for genetic testing (81479) provided June 25, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and 
pelvis (74177) provided on November 4, 2021. 
 
You asked the Plan to pay for a CT scan of the abdomen and pelvis. You say that the service at issue was a 
medical necessity for you. The Plan denied your request. The Plan says medical necessity rules for the service 
at issue have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are 
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 pay for a CT scan of the abdomen and pelvis. Our 
reviewer says that the service at issue is not medically reasonable and necessary in this case. Our physician 
reviewer found that the rationale for surveillance of the abdomen and pelvis is not explained in the submitted 
records. Your prior CT of the abdomen and pelvis of October 29, 2020, showed no evidence of metastatic 
disease. 
 
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 CT scan of the abdomen and pelvis have not been met. Therefore, we decided 
that the Plan does not have to pay for a computed tomography (CT) scan of the abdomen and pelvis (74177) 
provided on November 4, 2021.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for stress testing (78452, 93016, 93018) provided July 30, 2021. 
 
You asked the Plan to pay for the stress testing. You say that this service was medically necessary. The Plan 
denied your request. The Plan says the codes billed are inclusive to each other 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 CPT code. 
 
We find that CPT codes 78452, 93016, and 93018 are not supported in the medical record. Specifically, CPT 
codes 93016 and 93018 are inclusive to 78452. Based on this information, we decided that Medicare rules for 
coverage of the stress testing have not been met. Therefore, we decided that the Plan does not have to pay for 
stress testing (78452, 93016, 93018) provided July 30, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pay for imaging services provided to the enrollee on November 2, 
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 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 imaging services provided to the enrollee on November 2, 2021.